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SAN .JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> recd =Lj Cf�CD 2 S� <br /> OWNER/OPERATOR <br /> A 1c' YD ez <br /> CHECK if BILLING ADDRESS <br /> -� �s o^ <br /> FACILITY NAME <br /> SITE ADDRESS TA <br /> 6)-0 <br /> l S�� -' r""Y' �0 FLb�i 51 q 0 <br /> Street Number Direction Street Name Ci Zi3 Code <br /> HOME or MAILING ADDRESS 1(if / <br /> Different from Site Address) �q <br /> 3 0 I - 1 O/,I V+ l/ 1 'U,/Ay Street Number �V "Stree Na e <br /> CITYI O STATE ZIP—Aode <br /> CA- <br /> PHONE#1 I{- EXT• APN# LAND USE APPLICATION# <br /> Q-oq) I o 9 -51-13) <br /> PHONE#2 Ezr. EMAIL BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR M \ 1 D D �6il CL CHECK if BILLING ADDRESS 13 <br /> BUSINESS NAME - �� 'LIS (�s � I�� L� PHONE# EXT. <br /> TA(HOME or MAILING AnDDRESS ` C CJ FAX# <br /> CITY ���� STATE ZIP 9-53 L+ EMAIL <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity <br /> will be billed to me or my business as identified on this form. <br /> also certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards,STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: 6'J- 11-1 - 1013 <br /> PROPERTY/BUSINESS OWNER❑ OP ATOR/MANAGER ❑ OTHER AU HORIZED AGENT ❑ <br /> If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION:When applicable,I,the owner or operator of the property located at the above site <br /> address, hereby authorize the release of any and all results,geotechnical data and/or environmental/site assessment information to the <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It Is available and at the same time it Is provided t0 me Or my <br /> representative. Ar <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: D <br /> APR z y 2023 <br /> VIRONI N COUNTY <br /> HEALTH DE ARTMEN <br /> ACCEPTED BY: 3Y/Ccli!'t �l/lCtJGC�fiC EMPLOYEE#: 980&1 DATE: Q4(2 t f�2 3 <br /> ASSIGNED TO: �� EMPLOYEE M CIE, DATE: 'IZ`f -3 <br /> Date Service Completed (if already completed): SERVICE CODE: PIE:/&d)3 <br /> Fee Amount: 1/5-6. w o Amount Paid Payment Date 42-4123 <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 03/22/23 <br />