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ne e c�2 f $� <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR -Te-Cf r e � ocnd or J-Ci/1 P Pn (T <br /> ;-P l I tl CHECK If BILLING ADDRESS <br /> FACILITY NAME r o e-Ci , Q W H T J , U�' <br /> SITE ADDRESS lip 2- Cu-1(L,-\�,�O 1 �L — V— d L(1,4r,00 U 0 g 5 3 3 0 <br /> Street Number Direction St�nNNama city Zip Code <br /> HOME or MAILING ADDRESS (if Different from Site Address) y <br /> r 1 Cil <br /> �a�(_ `(� /1 ile-nuc <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> C)cc l�� c14(P01 <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> ( I ca (P Q 0-- 2101 -fi <br /> PHONE#2 EXT. EMAIL BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> Tolle en �Tc�A't o CHECK if BILLING ADDRESS <br /> BUSINESS NAME1 PHONE EXT. <br /> I (1�o- IeWd --FPS LUC r,IO duo- 2LI } <br /> HOME or MAILING ADDRESS FAX# <br /> 4- 01 F(. if .ftp owl ( ) <br /> CITY /i a- ,1`,, )(� STATE CA <br /> _ ZIP q y(00) 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. t/ <br /> APPLICANT'S SIGNATURE: DATE: f 17 <br /> PROPERTY/BUSINESS OWNER❑ V 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 assessmenPAr to the <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as Soon as It Is available and at the Same time It Is prfi#6t A(7hy <br /> representative. n ��� �+ c eIV <br /> TYPE OF SERVICE REQUESTED: M Ob i I e FOod CdV%Su-C, wry O q SEP <br /> COMMENTS: SAN <br /> HFA��JOAQUItV CO <br /> QEPW MAC T y <br /> NT <br /> ACCEPTED BY: �Y'1 y�11� EMPLOYEE#: DATE: Ct <br /> ASSIGNED TO: lL`e��h1� EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: <br /> Fee Amount: Amount Paid*/ a d Payment Date -3 <br /> Payment Type Invoice# Check# 1 2 Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 03/22/23 <br /> C <br />