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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />CHECK It BILLING ADDRESS <br />FACILITY ID #�,� <br />ASSIGNEDTO: <br />REQ C1ST # <br />EMPLOYEE#: <br />PHONE# Em. <br />0000 <br />SOL <br />SOL V5IV <br />OWNER/ OPERATOR <br />PIE: 62�pG/ <br />FAx # <br />2306 LoseLosee R <br />Amount Paid (Tis U� <br />( 702 ) 313-1712 <br />C TYh <br />CHECK It BILLING ADDRESS <br />San Toaquin General Hospital <br />Nevada 89030 <br />Check # <br />Received By: <br />FACILITY NAME <br />San Joaquin General Hospital <br />SITEADDRESS 500 <br />West <br />Hospital Road <br />French Camp <br />95231 <br />Street Number <br />Direction <br />Street Name <br />city <br />Zip Coda <br />HOME Or MAILING ADDRESS (If Different from Site Address) <br />Street Number <br />Street Name <br />CITY <br />STATE ZIP <br />PHONE #1 <br />Enr. <br />APN # <br />LAND USE APPLICATION # <br />( 209) 468-6000 <br />19305010 <br />PHONE #2 <br />Ext. <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />CHECK It BILLING ADDRESS <br />Brian Asa <br />ASSIGNEDTO: <br />BUSINESS NAME <br />EMPLOYEE#: <br />PHONE# Em. <br />Craft Construction Com an <br />702 639-9000 <br />HOME or MAILING ADDRESS <br />PIE: 62�pG/ <br />FAx # <br />2306 LoseLosee R <br />Amount Paid (Tis U� <br />( 702 ) 313-1712 <br />C TYh <br />STATE ZIP <br />ortL Veuas <br />as <br />Nevada 89030 <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 />1 also certify that I have prepared this <br />COUNTY Ordinance Codes, Standards <br />APPLICANT'S SIGNATURE: <br />PROPERTY / BUSINESS OWNER❑ <br />/f APPLICANT iS <br />ion and that the work to be performed will be done in accordance with all SAN JOAQUIN <br />RAL <br />and FEDElis. <br />DATE: 3/31/2022 <br />WTHORIZED AGENT ® General Contractor <br />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/s a assessment <br />information t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the it is <br />provided to me or my representative. R ^' tz!m 7 - <br />TYPE OF SERVICE REQUESTED: Plan review <br />COMMENTS: <br />Interior remodel of existing cafe and servery at San Joaquin General Hospital. <br />el tz Plate <br />ACCEPTED BY: f ✓� �S <br />EMPLOYEE #: <br />DATE: _ —2 <br />ASSIGNEDTO: <br />EMPLOYEE#: <br />DATE: <br />Date Service Completed (if already completed): <br />SERVICE CODE: �Z� <br />PIE: 62�pG/ <br />Fee Amount: <br />�e6 � <br />Amount Paid (Tis U� <br />Payment Date <br />c.f 2-2-- <br />ZPayment <br />PaymentType <br />t� <br />Invoice # <br />Check # <br />Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />