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representative <br />TYPE OF SERVICE REQUESTED: <br />Commas: <br />PROoOIgtA <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST • .ypc ui DUZillIESS or rroperty FACILITY ID # SERVICE REQUEST/ <br />S RO 6 OWNER / 0 • <br />2- <br />RATOR <br />CHECK ffilialgAIMMI L.. D 1.1, L., <br />FAcarrr NAME <br />z-Le,--, 6 <br />SrrEADI • z.. / <br />D Street Number <br />i,..) <br />Direction <br />c L'- <br />Street N3 rne <br />Lei: q ft YO <br />.. code <br />HOME or MAILING ADDRESS (If Different from site Address) 7 z 7 625/q /,' ---- Street Numbe ,hr Street Name <br />CITY ) <br />STATE ZIP <br />1 q 5-2- 0 <br />PHONE#1 <br />(2z7 -7) <br />APN # LAND USE APPUCATION# <br />PHONE#2 Err. <br />-7/ Z -7 y/G 5- EMAIL. <br />/01-7 i ? z . ,-. 4 <br />BOS DtSTRICT Loc.xraoNCooE <br />CONTRACTOR 1 SERVICE RE UEST R <br />REQUESTOR <br />CHECK if BILLING ADDRESS il <br />BUSINESS NAME PHONE* <br />( ) <br />EXT. <br />HOME or MAnitsc ADDRESS FAX/ <br />I I <br />Crry STATE ZIP EMAIL <br />BILUNG 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 ap, fication and that the work to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards, S ATE n EWAL laws. <br />APPLICANT'S SIGNATURE: <br />PROPERTY / BUSINESS OWNER , <br />If APPUCANT is not the BIUJNG PARTY proof of authorization to sign is required Title <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the <br />t <br />propertyNrilt.the above site <br />address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site asV Kt ki0q.fgero the rettetv <br />SAN COUNTY JOAQUIN COUN ENVIRONMENTAL HEALTH DEPARTMENT as soon as It is available and at the same time . Of my <br />ED <br />JAN 2 4 202, <br />SA N jo4 _uiN <br />1,4 <br />co 4N7T, <br />ENVIR,N <br />ti <br />,,a _NT4i. <br />..E4L 4/ DEP11147-(„NT <br />ACCEPTED By: EMPLOYEE #: <br />DAM <br />ASSIGNED To: - r ,--7 —, <br />LI i <br />EMPLOYEE #: <br />DAM /ZZ/Z ‘/ <br />P/E: 1 (, C -2 Date Service Completed <br />_ <br />(if already completed): SERVICE CODE (.(1, (c) <br />Fee Amount S 1 <br />_ <br />Amount Paid 1 u; — ,----- Payment Date <br />Payment Type a alQ Invoice # <br />1-• \---k 2_k5c,3 b Receved <br />BY: Al1P7( <br />EHD 48-02-025 <br />032223 <br />I. <br /> <br />SR FORM (GoIdFJ <br /> <br />OPERATOR / MANAGER 0 OTHER AUTHORIZED AGENT 0 <br />DATE: 2/