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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />Commercial <br />FACILITY ID # SERVICE REQUEST # <br />Si2 00Stilk--1 1 <br />OWNER / OPERATOR <br />CHECK if Haven of Peace / Ms. Olga Rodriguez, Executive Director BILLING ADDRESS X <br />FACILITY NAME <br />Haven of Peace <br />SITE ADDRESS 7070 <br />Street Number <br />S <br />Direction <br />Harlan Road <br />Street Name <br />French Camp <br />City <br />95231 <br />Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />Street Number Street Name <br />Cry STATE ZIP <br />PHONE #1 EXT. <br />( 209) 275-9110 <br />APN # <br />193-090-01 <br />LAND USE APPLICATION # <br />PHONE #2 Err. BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQU <br />REQUESTOR <br />Don Chesney, PE <br />- <br />CHECK if BILLING ADDRESS LJ <br />BUSINESS NAME _, , <br />Chesney Consulti q <br />PHONE # <br />( 209 ) <br />Err <br />402-1652 <br />HOME Or MAILING ADDRESS : <br />5 Osij <br />P.O. Box 3794!: <br />FAX # <br />CITY Turlock STATE CA ZIP 95381 <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 app ation and tha he work to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes„S'tandards,IF and FEleDr, /laws. <br />64, DATE: <br />PROPERTY / BUSINESS OWNER': OPERATOR / ANAG ER 0 0 ER AUTHORIZED AGENT El <br />//A PRUGINT is not the BILLING PARTY proof of author zillion 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 the same time it is <br />provided to me or my representative. <br />TYPE OF SERVICE REQUESTED: Expedited SSNL Study Review .--- ViC7Z--kitt&- 'Te-Czjii`ivr <br />- <br />COMMENTS: <br />4... <br />J4N / R <br />SAN ' 2022 <br />EttfirQUiN HE,40. RONm COON <br />H OSPA0.47AL 7/1 ... ratfE.A1 7. <br />ACCEPTED BY: <br />tr <br />EMPLOYEE #: DATE: <br />ASSIGNED TO: 6f0111-1 <br />EMPLOYEE #: DATE: <br />Date Service Completed (if already completed): SERVICE CODE: --2,,/- P 1 E: 74) 6 1_,...- <br />Fee Amount: <br />,11.Se <br />Amount Paituir /2.0D Payment Date 41 /2 , <br />Payment Type Invoice # Check # 377 s Received By:(18--- <br />APPLICANT'S SIGNATURE: <br />EHD 48-02-025 <br />SR FORM (Golden Rod) <br />REVISED 11/17/2003