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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Businitkor Property FACILITY ID # SERVICE REQUEST # <br />SCZOZ ts(0—A-cAL4 <br />OWNER/OPERATOR <br />CHECK if BILLING ADDRESS <br />FACILITY NAME L. a 5 AA_ o—r-- a - 5 <br />SITE ADDRESS I' 77/ 7 <br />Street Number Direction <br />C (I N c 0 k 54,0 <br />Street Name <br />c k4=-0,0 <br />City <br />cl G 7.0C Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />7_ "? ct c" Street Number OE LL) a 13 CA I4 rCk AA-- aStreet Name <br />1 Crry STATE <br />C kJ. CD kit <br />ZIP 1 t3 _ <br />PHONE #1 Exr. <br />( ) 9 6 — 7 RP\ kk <br />APN # LAND USE APPLICATION # <br />PHONE #2 Ext <br />( ) <br />EMAIL BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />ii r) <br />CHECK if BILLING ADDRESS <br />BUSINESS NAME L ,-.K <br />C3 <br />A-i' cx c in.' --- <br />PHONE # ( ) <br />Err. <br />HOME or MAILING ADDRESS <br />--7.___'• iA 3.--- p cx./ <br />FAX # <br />CITY <br />5 t' STATE ZIP <br />g S- 2 (2- <br />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 /> <br />DATE: 6 -o 2_ 3 APPLICANTS SIGNATURE: <br /> <br />PROPERTY! BUSINESS OWNER 0 OPERATOR! MANAGER 0 OTHER AUTHORIZED AGENT 0 <br />If APPLICANT /S not the BILLING PARTY, proof of authorization to sign is required <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: (-A.C.AD t f., fuld ptcuN_ ct.,..i._ c L PAYMEW <br />COMMENTS: RECEIVEI <br />JUN 0 5 202 <br />SAN JOAQUIN COU1 <br />ENVIRONMENTA1 <br />HEALTH <br />ACCEPTED BY: 1.Ackscci,..8,e, EMPLOYEE #: q BeDs_ DEPAR i rot DATE: /c /2_ s <br />ASSIGNED TO: L i lAs_ke4 ji .e.,,- EMPLOYEE #: Li %ei DATE: i2'C, /QS-7z. Z <br />Date Service Completed (if already completed): SERVICE CODE: 523 PIE: <br />-A.0 2, Fee Amount: ,A ("b . co Amount Paid # _ Payment Date Ws <br />Payment Type Vi 4) r Invoice # _c_hack-# / t, 3 3/ o 0 t, ; Received By: A-1-1- <br />Title <br />3 <br />S TY <br />NT <br />SR FORM (Golden Rod) END 48-02-025 <br />03/22/23