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Type of Business or Property <br />Direction Street Name City Zip Code <br />i 1 met /d Street Number <br />Ext.APN # <br />Ext.BOS District Location Code <br />CONTRACTOR / SERVICE REQUESTOR <br />Requestor <br />Business Name <br />,•> 1C < <br />Ave ) <br />City Zip <br />APPLICANT'S SIGNATURE: <br />CVigck,Type of Service Requested: <br />Comments: <br />NOV 1 8 2021 <br />Employee#:Date: <br />Employee#:Date: <br />Date Service Completed (if already completed): <br />Amount PaidFee Amount: <br />Invoice # <br />SR FORM (Golden Rod)EHD 48-02-025 <br />REVISED 11/17/2003 <br />PAYMENT <br />RECEIVED <br />Home or Mailing Address <br />LcZl <br />Ext. <br />o <br />San Joaquin County Environmental Health Department <br />SERVICE REQUEST <br />FACILITY ID # <br />Street Name <br />ZipState <br />Land Use Application # <br />lYic^ino <br />lcJi <br />4-^(o Cci.STArEa <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 <br />or activity will be billed to me or my business as identified on this form. <br />Check if Billing Address <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />SERVICE REQUEST# <br />Check if Billing Address D <br />Payment Type \ <br />Owner / Operator <br />Site Address <br />______________________Street Number <br />Home or Mailing Address (If Different from Site Address) <br />[jJ/ (7 <br />City <br />lWH 1 R(Cf <br />Phone #1 <br />gc/() t|C6- ^060 <br />Phone #2 <br />( ) <br />Phone# <br />(2^ /AZ- ^OO <br />Fax# <br />( <br />Accepted By: <br />Assigned to: <br />/IP/E; ^ol ~ <br />bl ^(2^ lb. <br />Received By: - / <br />Service Code: 2 3 <br />'—~~ | Payment Date <br />~ ChecK# <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 />WM .■ ■ _____________ Date: ]/- <br />Property / Business Owner Operator / Manager Other Authorized Agent <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 <br />above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment <br />information to the San Joaquin County Environmental Health Department as soon as it is available and at the same time it is <br />provided to me or my representative. <br />Pl m <br />N'tvO 'WiaVc "Z- -