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TitIe <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Bu ess or property <br />OLIAfC* <br />FACILITY ID # SERVICE REQUEST # <br />axgt,09-DI--1 <br />OWNER / OPERATOR _p 5sa —v\z/(-1- <br />FACILITY NAME <br />ADWil C4 IA E Ca.__, <br />Silk <br />Pi( <br />AMR ES S,., i;,eitiv,(4 <br />., ... rAtet-4umber Direction 1)1411k PaCiAC— St eet stp04/1 oc <br />ity <br />ct5-xq <br />Zip Code <br />HOME or MAILIrollf_Differei <br />I U <br />from Site <br />0 V--- \-- Street Number <br />Arc) , <br />Street Name <br />CITY <br />St C 10-01111 <br />T e(5,90q <br />PHONE #1 <br />c1/4(.10 <br />Exr. <br />gocv 10 <br />APN# LAND USE APPLICATION # <br />EXT. PHONE z4(63_0 34 3 EMAIL BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR , A ,-,i • <br />' it tAt cl'1 C1 (J) ide- CHECK if BILLING ADDRESS <br />BUSINESS NAMV ci tivm Careiv c Vi a PH °k .....,10-1,..0 EXT <br />HOME or MAILING ADDRES i ; P A C 1 C \ C A -•/'- e--- <br />FAX # <br />( ) <br />CITY STATE OA ZIP c hyl EMAIL - <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 or activity <br />will be billed to me or my business as id ied in this form. <br />I also certify that I have prepared this applic ;ti. n rd that the work performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards, STAT F 9E L I <br />DATE: <br />PROPERTY! BUSINESS OWNER OPE ATOR / MANAGER 0 OTHER A HO .!ZED AGENT 0 <br />If APPLICANT IS not the BILLING PARTY, proof of authorization o s n is required <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the above site <br />address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information to the <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is provided to me or my <br />representative. • <br />TYPE OF SERVICE REQUESTED: 00 <br />. L ,../ <br />! T. §-74 <br />D-61/tclid -riLVIX1-"--- TWIN <br />COMMENT : 4 MAY <br />( <br />SAN JOAQUIN ENV/ROA/Ai HEALTH DEp <br />RECEIVED <br />10 2023 <br />C°UNrY <br />egrAL ARTMENT <br />ACCEPTED BYM EMPLOYEE #: DATE: 0 10 23 <br />ASSIGNED TO: IbittteL EMPLOYEE #: DATE: <br />Date Service Completed (if already completed): SERVICE CODE: OW t P /E: i L0 6 Z. <br />Fee Amount: 4 )cv....— Amount Paid ISZp, 6?) Payment Date <br />Payment Type ciark Invoice # Check # ko 17 ,7 ocoto Received <br />APPLICANT'S SIGNATURE: <br />EHD 48-02-025 <br /> SR FORM (Golden Rod) <br />03/22/23