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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property FACILITY ID # SERVICE REQUEST # <br />5R.CIXDB-1 2130. <br />OWNER / OPERATOR <br />CHECK if BILLING ADDRESS WI CL,Vi GOleil 0 /27—C 0 V <br />FACILITY NAME <br />SITE ADDRESS <br />Street Number Direction Street Name City Zip Code <br />NOME or MAILING ADDRESS (If Different from Site Address) <br />4)e-tOc, c.... 1 LA—dt- Street Number Street Name <br />Crrsi, , STATE ZIP <br />410 Oor 40 4 CO- 9 5 2._o6 <br />PHONE #1 EXT. <br />(90) '2...5 9 - /5 •5/ <br />APN # LAND USE APPLICATION # <br />PHONE #2 Exr. <br />( ) <br />EMAIL BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />CHECK if BILLING ADDRESS IJ <br />( ekC•09 <br />BUSINESS NAME ,--N PHONE <br />1 <br /># EXT. <br />HOME or MAILING ADDRESS <br />YI e;' Ai A ri 14-Q-c. <br />FAX # <br />( ) <br />CITY 9 fo Lk. icy', ..". STATE c A ZIP q 52.0 C 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 /> <br />DATE: 0 5 APPLICANT'S SIGNATURE: <br /> <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 />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 to me Or my <br />representative. <br />r-Pri ritiMri 1 <br />TYPE OF SERVICE REQUESTED: VA Ok) i k FC (_ c..:‘ 'N (Lo Re \J l e_,A.. <br />RFCEIVED <br />COMMENTS: <br />OCT 0 5 2023 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />ACCEPTED BY:161.-i ctnn.e. tA. EMPLOYEE #: DATE: t ct, \ [KA 2:3 <br />ASSIGNED TO: z-e_e EMPLOYEE #: DATE: NctAGG k 2.3 <br />Date Service Completed (if already completed): SERVICE CODE: 52.-i P I E: \ k0 a) \ <br />Fee Amount: $46(0 , C)(f) Amount Paid q 8 i, Payment Date / 01, /2,3 <br />Payment Type LC,. Invoice # Check # Received By: <br />Title <br />EHD 48-02-025 <br />03/22/23 <br />csoc (-700q3 067 <br />erie g 1-70(9 LiR3FZiflGolden Rod)