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APPLICANT'S SIGNATURE: <br />PROPERTY! BUSINESS OWNER <br />DATE: <br />OPERATOR / MANAGER 0 OTHE AUTHORIZED AGENT 0 <br />ed2q12y <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property FACILITY <br />(P .(0 d 0 c -e (--' --- ym ci‘ .71\11011 <br />ID if <br />2 I 5 9 <br />SERVICE REQUEST if <br />bc2.(1)(1)BNOL\- <br />OWNER! OPERATOR <br />C CHECK if BILLING ADDRESS Raw\o <br />FACILITY NAME <br />\I 34 004/V R <br />SITE ADDRESS <br />3 (c, 0 0 Street Number <br />6 <br />Direction <br />/1 <br />-,-7 A <br />Liki CA:1-"-- i ° 280 Name "." `..- <br />s -toc 400 v- \ <br />City <br />— q -2-- <br />Zip Zip Code <br />HOME or MAILING ADDRESS (If Differe t from Site Address)._ <br />, 0 . R (YX q 6 Street Number Street Name <br />CITY i f STATE ZIP <br />r1001\r\. celn ci c-` 2. ‘o, <br />PHONE #1 s''' Err. <br />(20 ) (00 6 1/ e.,-6 <br />APN # LAND USE APPLICATION # <br />PHONE #2 EXT. <br />( ) <br />EMAIL BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />c3 am e. CHECK if BILLING ADDRESS <br />BUSINESS NAME PHONE # <br />( ) <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 />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 in jitalion to the <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is provi otricrillerAtt <br />representative. <br />TYPE OF SERVICE REQUESTED: C., Ik A ,5 .p 4:4 0 ‘,..) l' t -e se • 5-‘,.. : f) 4PR 29 <br />COMMENTS: <br />84/4/ <br />DATE : <br />DATE: <br />ki CM/MOWNElvrAL -EALrif <br />2024 <br />J0,4Qu <br />C°UNTy <br />-ramENT <br />Y1.9/71' <br />r eii/v/ <br />P/E: 1602_ <br />/2 21_ <br />ACCEPTED BY: c 1 4 u ch;:t 44 1, ro EMPLOYEE #: 9 ii./..er <br />ASSIGNED TO: / ita,v41407114 de) EMPLOYEE #: 9f2S <br />Date Service Completed (if already completed): SERVICE CODE: 06 I <br />Fee Amount: ip 1,4 j_.00 Amount Paid / co n De . Payment Date qizq <br />Payment Type CaA29( Invoice # ?mg_ :1 (W.--y --2( j2,9 Received By: <br />SR FORM (Golden Rod) EHD 48-02-025 <br />03/22/23 ?POI gLI