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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> au I - fA 0D0 28 50� a OD9-+ <br /> OWNER/OPE ATOR <br /> 0 CHECK If BILLING ADORES <br /> r/ _ M� � ) LIQ^ <br /> FACILITY NAME C I'`,o Kw i `C�(:a <br /> SITE ADDRESS `�lS Ni1 '5 �'LdC �-tel "192,0 3 <br /> Street Number Direction Street Name �1 Ci Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 Ex• APN# LAND USE APPLICATION# <br /> (Vy Ir&-S" t�1i -�-6 <br /> PHONE#Z ExT. EMAIL BOS DISTRICT LOCATION CODE <br /> ( 0) - 1 d 6`'l 3-e-Ye-oi J &5WP?4--Vf eon coo t h <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR �; <br /> JI CHECK If BILLING ADDRESS <br /> BUSINESS NAME A PHONE# EXT. <br /> 'v1 Sl 2,�J <br /> HOME or MAILING ADDRESS FAX# <br /> !/G 0 w 4\V <br /> CITY CF—y S TE ZIP O EMAI <br /> vG <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, ST and FEDERAL laws. I // <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER OPE /MANAGER OTHER AUTHORIZED AGENT ❑ <br /> If ApiDLICANT is the NG PARTY proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE IN ORMATION: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 thel <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It Is available and at the same time It Is provided apL my' <br /> representative. FN <br /> TYPE OF SERVICE REQUESTED: C V`6W <br /> COMMENTS: f\I.1, ^n r`�I <br /> JOA <br /> QU/ly ZO?y <br /> H Hi�Fp QAC <br /> FNT <br /> ACCEPTED BY: EMPLOYEE#: DATE: I ZL <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: /) P I E: <br /> Fee Amount• /L Amount Paid I Payment Date 2 <br /> Payment Type Invoice# Check# ��g�&3 Received By: <br /> EHD 48-02-025 SR FORM(Golden RQ ) <br /> 03/22/23 0 1 ill VS`4 <br />