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SAN .JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> si�003to-Iv2 <br /> OWNER/OPERATOR <br /> CA\�- CHECK If BILLING ADDRESS <br /> FACILITY NAME Tmccs N Je V/LA <br /> SITE ADDRESS 'W -v 1 Y y- C/\ &+- <br /> Sie,? �T) Z b <br /> Street Number Direction Street Name cityZi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) S-0 1 7 C1 `+411— �,, , / <br /> Street Number T�T/��Sttreet Name <br /> CITY STATE ZIP <br /> S C ' CA - S2- ) G <br /> PHONE#1 ExT. APN# LAND USE APPLICATION# <br /> ( Z-11 1 Tq -295-7 <br /> PHONE#2 ExT. EMAIL BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> r7A 1,-->' O Dun Y ili—c CHECK if BILLING ADDRESS <br /> BUSINESS NAME <br /> of vel- PHIE# _ 7EXT. <br /> HOME or MAILING ADDRESSO 1 FAX# <br /> � G �C1 �nU �C• ( ) <br /> CITY j _ STATE C 14- ZIP S7-2q 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, ST and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/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 prcy'ded to me or my <br /> representative. I ( A <br /> TYPE OF SERVICE REQUESTED: (/ (i Y I I(. I(/I c, <br /> COMMENTS: J(/ <br /> -&'%J0 C ?023 <br /> h FW Q0AI C <br /> �C?yoF�M��y <br /> r <br /> ACCEPTED BY: I/)/l EMPLOYEE#: DATE: 1-1—2 <br /> ASSIGNED TO: Y EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: PIE: <br /> r U <br /> Fee Amount: 2_ Amount Paid Payment Date -z 2 3 <br /> Payment Type Invoice# 5 2 Received y: <br /> EHD 48-02-025 • lX 2 r-aUP SR FORM(Golden Rod) <br /> 03/22/23 <br />