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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />Property <br />FACILITY ID # S VICE REQUEST # <br />(._ , Of <br />OWNER / OPERATOR <br />CHECK If Evelyn Albor Morales BILLING ADDRESS <br />FACILITY NAME <br />SITE ADDRESS 1262 <br />Street Number <br />N. <br />Direction <br />Fine Rd. <br />Street Name <br />Linden <br />City <br />95236 <br />Zip Code <br />HOME Of MAILING ADDRESS (If Different from Site Address) 1246 <br />Street Number <br />N. Fine Rd. <br />Street Name <br />CITY STATE ZiP <br />Linden CA 95236 <br />PHONE #1 Ex-r. <br />( 209)482-8656 <br />APN # <br />093-040-760-000 <br />LAND USE APPLICATION # <br />PHONE #2 Exr. <br />( ) <br />BOS DISTRICT LOCATION CODE . , <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTO R Chris Trapp CHECK If BILLING ADDRESS 111 <br />BUSINESS NAME <br />P( R§Ig ) 652-6549 <br />EXT. <br />HOME or MAILING ADDRESS 4590 Vista Dr. FAX # <br />l ) <br />CITY Loomis STATE CA ZIP 95650 <br />BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, <br />acknowledge that all site ancUor 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 and FEDERAL laws. <br />APPLICANT'S SIGNATURE: DATE: 5-11-21 <br />PROPERTY / BUSINESS OWNER0 OPERATOR / MANAGER 0 OTHER AU THORIZED AGENT 13 Agent of the Owner <br /> <br />yAPPLICANT is not the BILLLVG 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 ancUor environmental/site assessment <br />information to the SAN JOAQUIN COUNTY EN'1. TAL 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: N L S1).6IEW .I (,„ 1-6,1_1, i ch'ir4fe_ taciirij .S-teciS*0 <br />F COMMENTS: 9 t i ,,,,-/ v ,,e,,,t tiy1,20.1 i . (:..t u dy, Fa foled +0 oleo i els p e 61r - 1.1°C6 , 1 <br />ittefr <br />" < S4 N J0,4 <br />l'i l\IV IR8 LII N C AIL 7-- ncA/54,7_ i\iC <br />ACCEPTED BY: .4-----.2 Z.--Z__ EMPLOYEE #: DATE: Sfi aVd i 4 & 7-4; <br />Assi GNED TO: ry? EMPLOYEE #: DATE: Shdia? / <br />Date Service Completed Of already completed): SERVICE CODE: , PIE: dC2,2 <br />Fee Amount: 608.00 Amount Paid 608.00 Payment Date 5-11-21 <br />Payment Type Credit Card Invoice # Check # I, 2 3 — ig- 5— 13-\s- Received By: / <br />EFID 48-02-025 <br />REVISED 11/17/2003 <br />SR FORM (Golden Rod)