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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Geo 8216 3 <br /> OWNER/OPERATOR <br /> CATX Partners LLC CHECK If BILLING ADDRESS IM <br /> FACILITI'IeAME <br /> Mountain House Family Center <br /> SITE ADDRESS <br /> Street Nulhber Direction Street Name Cit Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> 5876 ASSISI CT Street Number Street Name <br /> CITY STATE ZIP <br /> San Jose CA 95138 <br /> PHONE#1 ExT. APN# LAND USE APPLICATION# <br /> (408 ) 666-3743 254-260-48 <br /> PHONE#2 ExT. BOS DISTRICT ILOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> Pradeesh Thomas CHECK If BILLING ADDRESS <br /> BUSINESS NAME CATX Partners LLC PHONE# ExT. <br /> 408 666-3743 <br /> HOME or MAILING ADDRESS FAX# <br /> 5876 Assisi CT ( ) <br /> CITY San Jose STATE CA ZIP 95138 <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 /> 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 d DERAL laws. <br /> APPLICANT'S SIGNATURE: Zr DATE: 11/24/2020 <br /> PROPERTY/BUSINESS OWNER 0 OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ Managing Member <br /> If APPLICANT is not the BILLING PARTY,proof of aatliorization 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 /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: <br /> p7 V �® <br /> U <br /> 8AN j ? 2020 <br /> ACCEPTED BY: EMPLOYEE#: f/ C <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: PIE: a <br /> Fee Amount: Q Amount Paid 3(/"l, Payment Date '2 2 20 <br /> Payment Type 11,1217 1Invoice# C cl—# I v Received By: <br /> EHD 48-02-025 D/1' I Golden Rod) <br /> ►/�/�i SR FORM( <br /> REVISED 11/17/2003 <br />