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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />rbo&;\--(-1:::4 <br />FACILITY ID # <br />FAOW 1 q 14 k -5 <br />SERVICE REQUEST # <br />SPO(2)8-440 44 <br />OWNER! OPERATOR <br />CHECK if BILLING ADDRESS <br />FACILITY NAME -r-- . 1 <br />oe,f I Gi <br />SITE ADDRESS ---r0 0 <br />Street Number <br />_tJ3t <br />Direction <br />tA)- ( .( \L (,)\( Street Name -V City <br />CI S-2/0 <br />Zip Code <br />1 <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />\ \.).P\ egC.1/1 0,06.(-) Street Number Street Name <br />CITY STATE ZIP <br />Uk1 CA ei(-0 <br />PHONE #1 Err. <br />(Y1) <br />APN # LAND USE APPLICATION # <br />PHONE #2 Ext. EMAIL <br />Ci -, \/- <br />BOS DISTRICT <br />, <br />LOCATION CODE <br />CONTRACTOR / SERVICE R QUESTOR <br />REQUESTOR CHECK if BILLING ADDRESS <br />BUSINESS NAME <br />1-49"). <br />PHONE # EXT. <br />HOME or MAILING ADDRESS <br />--A 40 (A) tik)64 4.fs'Q- 5 4-c Oi <br />FAX # <br />( ) <br />CITY <br />CA STATE <br />ZIP ) 0 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, STA FEDERAL laws. <br />/ <br />APPLICANT'S SIGNATURE: <br />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. <br />TYPE OF SERVICE REQUESTED: C,V)a.y1y... 0 C Oc.A)nex shi p rm.' nm_i. i <br />RECEIVED COMMENTS: <br />JAN 1 2 2024 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />ACCEPTED BY: G--i <br />\N \ O\C -\-\\(\-127 EMPLOYEE #: DATE: IV I 2.2 ‘2. Li <br />ASSIGNED TO: \J i das. p, EMPLOYEE #: DATE: (DI t 22 1 214 <br />Date Service Completed (if already completed): SERVICE CODE: 0 ._cl \ PIE: Vs OE <br />Fee Amount: ,A,v,z, ea Amount Paid / ,a ---- Payment Date <br />Payment Type V11-214_ Invoice # Cyc-IC # 1 q<25.--i 5-2, 2__ Received By: /4_1 <br />EHD 48-02-025 <br />03/22/23 <br />SR FO M (Golden Rod) <br />Pk0 5 2 qo <br /> <br />DATE: <br />7V PROPERTY! BUSINESS OWNER 4—OPERATOR / MANAGER 0 OTHER AUTHORIZED AGENT 0 <br />If APPLICAN not the BILLING PARTY, proof of authorization to sign is required