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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> SR®0871255 <br /> OWNER4 OPERATOR <br /> U!, l CA ( T CHECK If BILLING ADDRESS <br /> FACILITY NAME u V\ (� C <br /> COS <br /> SITE ADDRESS -VA <br /> j—i 5 I1 1 61/t S} of SZ L)(.0Street Number Direction Street Name " I Cit Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> 27d C A\) " Street Number Street Name <br /> CITY STATE ZIP, <br /> 5TO (AZ-1V r J <br /> PHONE#1 ExT. APN# LAND USE APPLICATION# <br /> 2o(1) 3 q 0 - 2�t �- <br /> PHONE 2Ex7. EMAIL BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTO 1��5 <br /> 0'J 7 A V CHECK If BILLING ADDRESS <br /> BUSINESS NAME C of PHONE �� �Z, _Exr. <br /> HOME or MAILING ADDRE S FAX# � <br /> 2 G 't o c -AV ( ) <br /> CITY $TATE • ZIP � EMAILl - QGC0 !�J q" <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business <br /> 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. <br /> APPLICANT'S SIGNATURE: c( ie-P. (�C'h�'i C U DATE: N U - �g 2 0,73 <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 assessmentAi�l�>pn to the <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It Is available and at the Same time It Is pr��ie�t ary <br /> representative. �+ Cc <br /> TYPE OF SERVICE REQUESTED: ;'� C' SEP <br /> COMMENTS: �lu� Ci1��LlL `SANJOAQU/ 3 <br /> N FNVIRONM COON <br /> EACTy of p R 7AL iY <br /> ACCEPTED BY: lI EMPLOYEE#: DATE: —2X —Z5 <br /> ASSIGNED TO: EMPLOYEE#: DATE: c� <br /> Date Service Completed (if already completed): SERVICE CODE: 2S I PIE: (� D <br /> Fee Amount: - A0— Amount PaidMVP1�- / Payment Date q Z� <br /> Payment Type i Invoice# Check# ��q SZ�s�2_ Receiv d By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 03/22/23 <br />