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SAN JOAQUIN COUNTY ENVI1ZONMEN"I'AL HEAL'I'FI DEPARTINIENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID## 1 SERVICE R/EQ/UEST# <br /> Y OVYNER J OPERATOR CHECK If BILLING ADDRESS❑ <br /> FrtcluTY NAME S U R W f I c�rT .LJW V�C <br /> t <br /> SIT£ADDRES S ,.1 • MARc� �1�1, 5 r x.1310 �7oG�.To/�1 ���`� <br /> �'. 2-919 <br /> Shaot N�mbcr Direction Str o Nems Clt ZI Cadre <br /> H04tE or MAILI'r`G ADDRESS (If Different from Site Address) <br /> Stroot Number rr C I� Str et Name <br /> cr: C" STATE <br /> zip -31 <br /> C-4 9Sit PHONE#1 ExT• APN# LAND USE APPLICATION# <br /> t� (2zO <br /> PHONEA2 E"T• BOS DISTRICT LOCATION CODE <br /> I <br /> OIL <br /> is <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR r <br /> r: REQUESTOR <br /> T LS if CHECK If BILLING ADDRESS <br /> BUSINESS NATAE t�! PHOiIE# 7 Q T' <br /> Hormf or MAILING AD RESS <br /> FAx <br /> F 2 ( ) <br /> STATE G ZIP <br /> C1TY J J 1 <br /> BILLING ACKNOWLEDGEMENT: 1, the undersigned property or business owner, operator or authorized agent of same, <br /> acluiowledge that all sire and/or project specific EWRONMFNTAL HEALTH DEPARTNIENT hourly charges associated with this project <br /> or activity 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 w to be performed will be done in accordance with all SAN JOAQUIN <br /> COL;NTY Ordinmice Codes,Standards,ST TE and F DERAL law <br /> APPLICANT'S SIGNATURE; DATE: 271,2,nZ 3 <br /> PROPERTY/BDSINESS OWNER❑ OPERATOR/MANAGE ❑ THER AUT11oRrLCD AGENT❑ <br /> IfAPPLICAA'T t.r rot the BILLlNCPA.RTY,proof of authorization to sign is required Ttrta <br /> AUTHORIZATION TO RELEASE INFORMATION:When applicable,I,the owner or operator of the property located at the <br /> aoove site address, ]rereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DAPARTMENT as Soon as it is available and at the same time it is <br /> provided to me or my representative. PA <br /> TYPE OF SERVILEREQUEST£D: I <br /> Ct%>,',NENT$: i �r •�p�r�l/ APR 2 7 2023 <br /> f SAENJCAQUII� <br /> MEALTy0EPARTMENT <br /> I � <br /> 3 ACCEPTED BY: tall <br /> EMPLOYEEM DATE: � <br /> ASSIGNEDTO: EMPLOYEE#: C� DATE: <br /> Date Service Comp ted (if already completed): SERVICE CODE: �; P 1 E: j ,r <br /> Fee Amount: t Amount Paid ����� Payment Date .27 <br /> payment Type t Invoice# Check# ' ���� Received By: <br /> SR FORM(Golden Rod) <br /> 02-025 l• <br /> El•ID ....e=§.Y.:-b,::i•. �- --._.._.-�ca................e:6....•. u:,+ak:::c.s..n. -�mru• <br />