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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />ObiItbone co- <br />FACILITY ID #SERVICE .--- <br />01000 .7., <br />REQUEST # <br />cP)OOLOW/I <br />OWNER/ OPERATOR <br />() <br />CHECK if BILLING ADDRESS <br />FACILITY NAME Owcynome „ <br />SITE ADDRESS S <br />q 116/4 Street Number 1 Direction <br />, <br />/ Cilet Name <br />y--c(kyon <br />CI <br />7521 L. <br />Zip Code <br />HOME or MAILING AlPr5ESS (If Different In dress) <br />-r- 0 Street Number Street Name <br />STATECA CITY (00_,KLO ZIP 753(4 <br />EXT. PHONE #1 6 5gleao <br />(26( ) <br />APN # LAND USE APPLICATION # <br />Pr( )t-tci--362,..... <br />2, EXT. BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR _My/0- <br />CHECK if BILLING ADDRESS <br />BUSINESS NAME illOW <br />41(tf_ tpn <br />eltpeAti Mil/4f, P(Hrnet-6-3Pip /EgiO <br />HOME or MAILING ADDRESS 0, es4 1 tIZ I <br />FAX # <br />(2_0q ) 8145-3835 <br />CITY (A airit, STATE 0A zip q59L0 ) <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 HEALTII 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 b rmed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards, ST ai4-*F ERAL la <br />APPLICANT'S SIGNATURE: s/\-(N- r 10 DATE: 1/q/2022. <br />PROPERTY/ BUSINESS OWNERD SE i.ATOR / MANAGER OT UIFIOADV AGENT 0 <br /> <br />If APPLICANT is not the BILLING PART'Y, pr 9óf of authoriza ti 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 tlksame time it is <br />provided to me or my representative. <br />• <br />TYPE OF SERVICE REQUESTED :ITICita'n/ 007:-(4 ft,flevelv ---- t_117\i/ <br />COMMENTS: <br /> <br />i4A1 4 0 h <br />SAN f 2022 J0,1 n <br />/-1 ,:ViVrt/iRCtifiN CO u <br />Fl Ctp,V.416A17-4 LA/rY <br />R 7-4,7E.N 7. <br />ACCEPTED BY: ,f itit EMPLOYEE #: DATE: <br />ASSIGNED TO: 4/OrgRi EMPLOYEE #: DATE: ( <br />Date Service Completed (if already completed): SERVICE CODE: ••'')/ P / E:47/0 i <br />Fee Amount: 4, n v i Amount Paid 30L-4 Ct) Payment Date <br />Payment Type i' i Invoice # Check # j 36 s- 7 q Received By: (725 <br />A A <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003