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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property FACILITY ID # <br />FA a) 1 CI —110 V) <br />SERVICE REQUEST # <br />OWNER/OPERATOR koceya \A e CHECK if BILLING ADDRES 0 <br />FACILITY NAME <br />Vit Wift S S-2 0clivt_ce 3 g. A 5 0 2Ap <br />SITE ADDRESS 2-1 q <br />Street Number Direction <br />"Frevkal cart-t-e gel <br />Street Name <br />-TY‘e-vol, cavy <br />City <br />q Cz3 I <br />Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />I t °(-4 `1 <br />Street Number <br />ISoc-4 fed <br />Street Name <br />. <br />CITY STATE eA ZIP oi s.51.42 1 <br />Da V (kaki) <br />PHONE #1 Ex-r. <br />(Lk/4 ) 1 • - ' RC. <br />APN # LAND USE APPLICATION # <br />PHONE #2 Ex-r. <br />( ) <br />EMAIL BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />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, t ndersigned property or business owner, operator or authorized agent of same, <br />acknowledge that all site and/or projec ecific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project Or activity <br />will be billed to me or my busine 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 />APPLICANT'S SIGNATURE: <br /> <br />DATE: <br />PROPERTY! BUSINESS OWNER 0 OPERATOR / MANAGER 0 OTHER AUTHORIZED AGENT 0 <br /> <br />If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required <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: r-ODA Veck4 I, v6 re, <br />_. <br />-,P,0-1, fi•eel twEi eiv4 COMMENTS: <br />CA/lot v•tcr 1-)g..kfte4C- s 149nel 00ale LI Git-. gW51 I 2-(0 1414)/ 0 2 2m SAN Jo A Li4 <br />EIVVII7 Q UN CO IIPAL. ri, PAIMEA,,UN <br />" UE/31/4•21.7v: <br />ACCEPTED BY: 0611-^ EMPLOYEE #: DATE: 5- 2-0_1 <br />ASSIGNED TO: _..A.., EMPLOYEE #: DATE: <br />Date Service Completed (if already completed): SERVICE CODE: -0(0 i P/E: ((.O3 <br />Fee Amount+ .. Amount Paid 5 ( (..9 2 , Payment Date 54e2it <br />Payment Type /TA011.) Invoice # Check # Received By: 660-7/f' <br />EHD 48-02-025 SR FORM (Golden Rod) <br />03/22/23 <br />FR19 3 COSci