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M <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE RE�QUEST# <br /> Licensed Health Care Facility OI�D�(7��1 �� ()N-1L113 <br /> OWNER/OPERATOR <br /> CHECK if BILLING ADDRESS <br /> Kalesta Healthcare Grou <br /> FACILITY NAME <br /> St. Jude Care Center soon to be Harvest Crossing Post Acute <br /> SITE ADDRESS 469E North Street Manteca 95336 <br /> Street Number Direction Street Name c1tv Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Sheet Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 En. APN# LAND USE APPLICATION# <br /> (209)823-1788 114 <br /> PHONE#2 Ex. BOS DISTRICT LOCATION CODE <br /> (760 1519-7531 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR Mark Baddas u)J� -4 6 0 5Iq :P;'31 CHECK If BILLING ADDRESS <br /> BUSINESS NAMEKalesta Healthcare Group PHONE# 114 <br /> (209)823-1788 <br /> HOME or MAILING ADDRESS 469 E North Street FAX# <br /> (209)823-9809 <br /> CITYManteca STATE CA z"'95336 <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. c <br /> I also certify that I have prepared this application and that the work to be performed will be done in accordance with all Spi�Kp <br /> COUNTY Ordinance Codes,Stand�p(!Ss I FEDERAL laws. l• /VAc <br /> IIIIII ° <br /> APPLICANT'S SIGNATURE: pptt DATE: 10/26/2021 _ OCT 1 R ?Q <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER tq OTHER AUTHORIZED AGENT 11 N��/a <br /> IfAPPLICANT is not the BILLING PARTY proof of authorization to sign is required HW /y O M COL//v T <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, I,the owner or operator of the property to�eed'aa8ftw� Y <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessmentNT <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:Change of ownership Inspection <br /> COMMENTS: <br /> Change of ownership from Joseph Palitvathucal to Kalesta Healthcare Group will occur on November 1, 2021. <br /> Change of ownership inspection needs to be completed please. Thank you. <br /> ACCEPTED BY: EMPLOYEE#: DATE: l p <br /> ASSIGNED TO: EMPLOYEE#: DATE; V 17-3 /1 <br /> G� <br /> Date Service C mpleted (if already completed); SERVICE CODE: -V P I E: <br /> Fee Amount: �S 2-— Amount Pal IS .06 Payment Date o2 <br /> Payment Type C,tC,t;� Invoice# Check# / �! bg` Receive By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17Y2003 <br /> (�� 052'130-7 ,S <br />