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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> cji,xbWCA Storms e72 <br /> OWNER/OPERATOR r Ate' f <br /> K ,�a.Y St S�Int� CHECK If BILLING ADDRESS❑ <br /> S � I <br /> FACILITY NAME / h <br /> SITE ADDRESS J (� f y C% Z,:)Vd S'%U Gk To <br /> dog Street Number Direction Street Name City Zip Code <br /> HOME or MAILING <br /> //ADDRESS (if Different from Site Address) <br /> AZJ <br /> C9 ct i Street Number Street Name <br /> CITY n, ^ ' STAT ZIP <br /> PHONE#1 Exr. APN# LAND USE APPLICATION# <br /> (�)0 IZI-f S(0- -�,' <br /> PHONE#2 ExT• EMAIL BOS DISTRICT LOCATION CODE <br /> ( ) C' <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR FO PMAO <br /> f� �; f <br /> r �J l,vt �•L� CHECK If BILLING ADDRESS <br /> BUSINESS NAME (J� Pat a N � PHONE# ExT• <br /> J / 1 l ' l ) ,, <br /> 3, , <br /> HOME Qr MAILING AD RES((S nn r FAX# <br /> CITY <br /> S STATE CH ZIP %-0 12 EMAILS iN.�jt1�'c�lP o i�Ca) <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 /> I also certify that I have prepared this application and that the work to be p rformed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards, STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: ` DATE: (3�I Uyx <br /> PROPERTY I BUSINESS OWNER OPERATOR/MANAGER ❑ OTHER AUTHORIZED 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. <br /> TYPE OF SERVICE REQUESTED: w ()-r� )q G <br /> COMMENTS: U RECEIVED <br /> MAY 0 1 2023 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: �l� 223 <br /> Date Service Completed (if already completed): SERVICE CODE: P E: C)� <br /> Fee Amount: S Amount Paid l _ Payment Date yp L 3 <br /> Payment Type 162 Invoice# C ck# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 03/22/23 <br />