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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of of Business or Property FACILITY ID # SERVICE REQUEST # <br />S 1' a) g-s cl s <br />OWNER / OPERATOR 00 '2-1 "2-2_(13 CHECK if BILLING ADDRESS A FPC <br />\V-K. 7 \4-\\ c? <br />FACILITY NAME <br />V ,N 0 r\ L <br />SITE ADDRESS <br />/ ? 1 -7 Street Number Direction ) /1.-7 __..5 Li :\ 1 CTIVANatri t City Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />Street Number Street Name <br />CITY STATE <br />C - ,--- <br />ZIP , <br />PHONE #1 Err. <br />(rk CI -W-1 <br />APN # LAND USE APPLICATION # <br />PHONE #2 Err. <br />( ) <br />EMAIL BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />CHECK if BILLING ADDRESS <br />BUSINESS NAME \ PHONE # Ex-r. <br />HOME or MAILING ADDRESS FAx # <br />CITY c- F STATEC <br />--It_r--„---- k a ZIP 9 5 6 4„ 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,_S-EATE and FEDERAL laws. <br />APPLICANT'S SIGNATURE: <br />PROPERTY! BUSINESS OWNER 0 OPERAT / MANAGER Ii 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 i to the <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is prole <br />representative. CE. <br />TYPE OF SERVICE REQUESTED:a V a Chik 0 V vls, vech,c‘_,— i-Zo iv 0 0 - 4.;•-u <br />COMMENTS: <br />eivvct o 0.,0AQ,"‘51A-A--9 <br />4 okv Jo . 2024 evvilQubv iv,44r Romil cow., <br />8czpA,E^0;44 7)" ,7 4/ EAT <br />ACCEPTED BY:IVU\ EMPLOYEE #: DATE: 1-9 — <br />ASSIGNED TO: KA EMPLOYEE #: DATE: <br />Date Service Completed (if already completed): SERVICE CODE: N( P/E: i (v03 <br />Fee Amount:, lk.02 _ Amount Paid ((c2 --- Payment Date I .9 (2+ <br />Payment Type aakk, Invoice # Check # Received By: aty7. <br />DATE: /-+ <br />Title <br />SR FORM (Golden Rod) END 48-02-025 <br />03/22/23 5