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I also certify that I have prepared thi <br />COUNTY Ordinance Codes, Sta • : <br />ication an <br />, STATE and <br />hat the work to be pe <br />ERAL laws. <br />rmed will be done in accordance with all SAN JOAQUIN' <br />APPLICANT'S SIGNAT RE: <br />PROPERTY / BUSINESS OWNER PERATOR T ANAGER CI OTHER AUTHORIZED AGENT 0 <br />If APPLICAN Is not the BILLING PARTY, proof of authorization to sign is required Title <br />DATE: <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property FACILITY ID # SERVICE REQUEST # <br />SRM 816;11 <br />0301.NER / OPERATOR (--- CHECK if BILLING ADDRESS <br />--L9Q_DiP"\--e- <br />FACILITY NAME r \ <br />S C__ if (—in <br />SITE ADDRESS c qe'( <br />1 I 6 e AD' i UL)StreeNuml)er <br />k2-0 CI <br />Direction Street Name ( ifa.) City <br />r) 5 Zt--14 6 <br />Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />1_ ry {6 . . Street Number <br />7{A/ t'1 5 ci r feg aci --E-I'l Street Name <br />CITY STATE /.-- ZIP <br />Q1 76 <br />PHONE #1 XT <br />06:), (A.(4 0) --7e <br />APN # LAND USE APPLICATION # <br />PHONE #2 EXT. <br />( ) <br />EMAIL BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR CHECK if BILLING ADDRESS <br />BUSINESS NAME PHONE # <br />( ) <br />Err. <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 ota-t 01111. <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 asses st information to the <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it irArmeArri Of my' <br />representative. <br />TYPE OF SERVICE REQUESTED: PA 1 r liec 4 AFF AN 3 i <br />COMMENTS: 1 2024 SAN •-•%/ u, AQUiN <br />ENVIRONm C°UNTY <br />HEALTH DEp EINITAL <br />ARTMENT <br />- <br />ACCEPTED BY: <br />r <br />f- /26(//- EMPLOYEE #: DATE: <br />//3 <br /> I 2 q <br />ASSIGNED TO: <br />-F", (2, <br />EMPLOYEE #: DATE: //3j /2/ <br />Date Service Completed (if already completed): SERVICE CODE: 5"---Z1 PIE: ico l <br />Fee Amount: k9 Liiin 6, ffic7 Amount Paid 5 q__R, 7 , (-5- Payment Date 1/3//22.t. <br />Payment Type _i_ <br />I I <br />Invoice # Check # 175 7 2_1 if cr-r i Received y:fillir <br />EHD 48-02-025 <br /> SR FORM (Golden Rod) <br />03/22/23 <br /> <br />FR W-W,411--7