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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property FACILITY ID # SERVICE REQUEST # <br />OWNER / OPERATOR <br />... CHECK if BILLING ADDRESS N.,k-Nr\szi...i-- ••-.1< S . \N. NN <br />FACILITY NAME <br />ADDRESS SITE ADDRESS <br />L Street Number Direction ...--.. Street Name SC es,c.:Nts. C.--v*-'cNNR, City ' -\ •Z•C \N Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />c--. --__, c----S--4--- e , Street Number <br />C......-4-',,. c.-• c ; ' S\ <br />Street Name <br />CITY STATE ZIP <br />PHONE #1 Err. <br />(aGN \r--"r--c\c"\ <br />APN # LAND USE APPLICATION # <br />PHONE #2 Ex-r. <br />( ) <br />EMAIL <br />C:----\--.\ SZ-- \e'• c--- C.- 'CC.1\; \ ,ts,I.i. <br />BOS DISTRICT <br />----z.. ,...., <br />LOCATION CODE <br />q q <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />.,1 Ill -e- <br />CHECK if BILLING ADDRESS <br />BUSINESS NAME PHONE # <br />I ) <br />ExT. <br />HOME or MAILING ADDRESS FAX # <br />( ) <br />CITY STATE ZIP 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 />I 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: Si I 0 '12.3 <br />PROPERTY! BUSINESS OWNER 0 OPERATOR / MANAGER 0 OTHER AUTHORIZED AGENT 0 <br />If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required <br />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 pgr.pvided to me or my <br />representative. "AY <br />TYPE OF SERVICE REQUESTED: C E q......S C.„._„.... ,,--\."---kr--\\•-:.0 --A NEceu,,--- i - i'.:1 <br /> <br />COMMENTS: AUG 0 ? 2023 <br /> <br />C._ ‘Q--. -c C._s,„••.k-,-.S..-cs-c\.C1 \IN SAN JOAQIEN <br />ENVIRON C°UNTY hEALTH DepALENTAL <br />rvITAIENT <br />ACCEPTED BY: t_frei __ed <br />EMPLOYEE #: c.c-,,,.:,c, .C.., DATE: % (C (z:s <br />ASSIGNED TO: .i°A - EMPLOYEE #: DATE: <br />Date Service Completed (if already completed): SERVICE CODE: 0 6) I P/E: 417;1 iti o <br />Fee Amount: *\ C '7 Amount Paid --- <br />(7 I- 6 0 <br />Payment Date <br />Payment Type paNt Invoice # $146t41 1 (.1)U8D b as 2 Received By: Wrii( <br />EHD 48-02-025 <br /> SR FORM (Golden Rod) <br />03/22/23