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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />SH•i-Vg- (cE <br />FACILITY ID # <br />(DC) 11/44'9-5 <br />SERVICE REQUEST # <br />3(4 24 <br />OWNER / OPERATOR <br />AlAiki c isi. AlAiq CHECK if BILLING ADDRESS <br />FACILITY NAME / 0 5 E_AfP4.E.4--oak ---\-- Z-D <br />SITE ADDRESS 2 t 3 0 <br />Street Number Direction <br />PAC /A .‘ AYE, <br />Street Name <br />57 011<70 Al <br />City <br />95-2-ot <br />Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />6 5-13 7' /it C/ 64 A vC .. .41 z 05- Street Number Street Name <br />CITY STATE ZIP <br />TO el< MA/ eit- <br />PHONE #1 #1 EXT. <br />(7-0 4?) 5-10 /5 2-7? <br />APN # LAND USE APPLICATION # <br />PHONE #2 EXT. <br />( ) <br />BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />CHECK if BILLING ADDRESS <br />BUSINESS NAME PHONE # <br />( ) <br />EXT. <br />HOME or MAILING ADDRESS FAx# <br />( 1 <br />CITY STATE ZIP <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 applic nd that the work to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards, ST F d DERAL laws. <br />DATE: <br />PROPERTY! BUSINESS OWNER " OPE ATOR / MA AGER 0 OTHER AUTHORIZED AGENT 0 <br />If APPLICANT IS not the BILLING PARTY, proof of authorization 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 HEALTI I 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: ? \ c---.(-\ Vs----9--Ck A------06 C - <br />— <br />COMMENTS: <br />- ECE/Velb) <br />co A31 C 2 2023 SOW 0294%4, <br />Wil/.41117°94.4•41r‘tri, <br />ACCEPTED BY: L -,, r\,\,-,\,,,4 _e s EMPLOYEE #:\„k.. '<1 q' DATE: 2 _L)8:"12.."1 <br />ASSIGNED TO: `-e) V ja_A...... EMPLOYEE #: DATE: a _ 22 _ 23 <br />Date Service Completed (if already completed): SERVICE CODE: 2 _% PIE: k bo I <br />Fee Amount: --._. 02 _ Amount Paid <br />-4C2 :--- <br />Payment Date 224 2 <br />Payment Type (1/2)L9 Invoice # pitel--, S 49-01CO3(2 Received By: <br />APPLICANT'S SIGNATURE: z 2 17 <br />EHD 48-02-025 <br /> <br />SR FORM (Golden Rod) <br />REVISED 11/17/2003