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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />AA FT= <br />FACILITY ID # SERVICE REQUEST # <br />SRCbCD 6-4 c't C)ICD <br />OWNER / OPERATOR 6-61Li J-16,foard CHECK if BILLING ADDRESS <br />FACILITY NAME H 1 <br />61Y 6-10J) riRc -e <br />SITE ADDRESS '' 'i ; 4--- , , <br />Street Number <br />r <br />Direction we 6cr / 4 Je. <br />Street Name <br />,(:),(- (( I-62-7 <br />City <br />q12,Z <br />Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) I 7 "1 <br />Street Number //f)C( 4/ Street Name vt.- <br />CITY <br />S10 t 00/7 <br />STATE ZIP <br />(4 <br /> <br />g‘52-et <br />PHONE #1-0c() Exr. <br />aiKr 62- (JO <br />APN # LAND USE APPLICATION # <br />PHONE #2 Exr. <br />( ) <br />EMAIL BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />---1/\---0,4,,C,--,, 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 w k to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards TATE and FEDERAL laws. <br />APPLICANT'S SIGNATURE: DATE: - <br /> <br />PROPERTY! BUSINESS OWNER 0 OPERATOR ANAGER 0 • OTHER AUTHORIZED AGENT 0 <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 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: tk./Q il"( k- 60-c± PAYMENT <br />COMMENTS: MF.1 I 64--1ASkOLUtv, <br />APR <br />SAN JOAQUIN <br />RECEIVED <br />ENVIRONMENTAL <br />25 2024 <br />COUNTY <br />DEPARTKNT r <br />DATE: 1—t/2-<5 ( 2-I-1 ACCEPTED BY: EMPLOYEE #: (7 z I 3 HEALTH <br />ASSIGNED TO: k. ,, A v 0 <br />Service <br />. EMPLOYEE #: DATE: 4 / 2 c /2_'- <br />Date Completed (if already completed): SERVICE CODE: <br />Payment Date <br /> t b D Ny <br />Fee Amount: Amount Paid t/ 02. <br />Payment Type Vi ') Invoice # yetf# / g b (i/O.c q--c) Received By: 1, <br />END 48-02-025 <br />03/22/23 <br />SR FORM (Golden Rod) <br />T0)51461 QC