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vu— (\€€c\,2 19 12, <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property FACILITY ID # SERVICE REQUEST # <br />ef^' SSCI <br />OWNER! OPERATOR c k <br />' (Arc) {g , CLAy\o,-,er CHECK if BILLING ADDRESS <br />FACILITY NAME 0 1- ogri ' a d CcIAAAR EV To (Lai+ YDe -40-0,1 pim21 <br />SITE ADDRESS ‘ 62_0 i <br />Street Number <br />S <br />Direction <br /> <br />t' k-t a.cv.1 ir.0 cLA “ L-vi <br /> <br />Street Name <br />y <br />Laki+111-17 <br />City <br />9 (3go <br />Zip Code <br />HOME Or MAILING ADDRESS (If Different from Site Address) <br />16R--(1 Street Number ,(z_A---i- Le if 4--r 1— Street Name <br />CITY <br />,CL-1-41 )--06p <br />STATE <br />Cei <br />ZIP 9 Cjg • ? r ) _ <br />PHONE #1 EXT. <br />L570 ) ? 6 3 <br />APN # LAND USE APPLICATION # <br />PHONE #2 Ex-r. <br />( ) <br />BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR r f _k . A .1' CI ? n ' C tA110\'-'r CHECK if BILLING ADDRESS <br />BUSINESS NAME <br />EN1Q-Y- Si- <br />A <br />Ta yvzi 0 D-Y I cu-vid C40-11-0., <br />PHONE # <br />(53 0 <br />EXT. <br />S 6g ';iC-13 <br />HOME or MAILING ADDRESS (6 ..4... <br />?-9 c.c4- I- Le.-1 C <br />FAX # <br />( 1 <br />CITY Lo1/4.4.1/..yro p STATE <br />C4 <br />ZIP oi 5 7y0 <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 application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards, STATE and FEDERAL laws. <br />APPLICANT'S SIGNATURE: DATE: b .-2 -24 <br />PROPERTY! BUSINESS OWNER 0 OPERATOR! MANAGER 0 OTHER AUTHORIZED AGENT 0 <br /> <br />If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required <br />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 at the same time it is <br />provided to me or my representative. <br />PAYMENT TYPE OF SERVICE REQUESTED: .1Dd FC.AVA alk0 Ck-- ( cD(592f2/\.) <br />COMMENTS: RECEIVED <br />MAR 2 9 2023 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />ACCEPTED BY: EMPLOYEE #: DATE: <br />ASSIGNED TO: t_.... \ c\ \t`-\ c\ i eff-, EMPLOYEE #: DATE: <br />Date Service Completed (if already completed): SERVICE CODE: C32 -5 RI : / (00 1 <br />Fee Amount 14 g ---- Amount Paid 4 k ,6 Payment Date <br />Payment Type v 1 ,--, fk invoice # "ea # 1se- 1, 0 / ,.__.q Received By: <br />SR FORM (Golden Rod) END 48-02-025 <br />REVISED 11/17/2003