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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> FA 00010 35 SROQ) S3q 27 <br /> OWNER/OPERATOR <br /> /t � CHECK If BILLING ADDRESS❑ <br /> FA�IrLITTY NAME <br /> NSA <br /> w, <br /> SITE ADDRESS I—1-q j -1 E , 1 w 101© R p O'(\ g C5 S(9 i60 <br /> Street Number Direction i� Street Name city Zip Code <br /> J HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#t EXT. APN# LAND USE APPLICATION# <br /> ('109) qIN- 51 VZ 0103- 1190lao <br /> PHONE#2 ExT. EMAIL BOS DISTRICT LOCATION CODE <br /> ( ) 99 <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# ExT• <br /> ( <br /> HOME or MAILING ADDRESS FAX# <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 /> 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, Z5JATE and FED AL laws. <br /> .APPLICANT'S SIGNATU �. DATE: 0q12 S 12 0 2 L/ <br /> PROPERTY/BUSINESS OWNER L`J RATOR/MANAGE 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 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. w V <br /> TYPE OF SERVICE REQUESTED: PAYMENT <br /> MENT <br /> COMMENTS: <br /> APR 15 2024 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE#: DATE: 4. 'd *3 <br /> ASSIGNED TO: i 1 EMPLOYEE#: DATE: 4- <br /> 95 <br /> , 3 <br /> Date Service Comple ed (if already comple d): SERVICE CODE: O W 1 PIE: <br /> Fee Amount: W91 Amount Paid Z Payment Date _2_� .Zv <br /> Payment Type �� Invoice# Ch #6 U b J Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 03/22/23 11 `�� <br />