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SAN JOAQUIN COUNTY ENVIRONMEN TAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />:101) -TgiiCi. <br />FACILITY ID # SERVICE REQUEST # <br />W,007z>1(04 <br />OWNER / OPERATOar -1/1 2) CHECK if BILLING ADDRESS <br />FACILITY NAPAE 7 it) I- D o G-S Lis M .6- <br />SITE 17 2. <br />"....7 Street Number Direction g--D FL1 t-F7'6Ni 11\1/ <br />Street Name <br />MANTECA- <br />City <br />C7 . <br />Zip Code <br />7 <br />Ho or A 17S (If Different from Site Address) . , <br />I D "pg ok.1 in Street Number Street Name <br />CITY M S(1,1 <br />-7 qZ1cP 3 <br />frefikl 7_60.1_ <br />PHONE #1 E APN 21P14220 7 <br /># <br />a (30-57 <br />LAND USE APPLICATION # <br />PHONE #2 Err. <br />1) ?,2J --1 -73 -7 00 3 <br /> BOS DISTRICT LOCATION CODE <br />vlan-1-eca <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR .,E0- u 6 r y6Ae. jog <br />CHECK if BILLING ADDRESS <br />BUSINESS NAME LIZ Paiil )-0.1 -3367 <br />Err. <br />t /1 '5 1/61-COS 4 IqDr2 Ei, <br />I HomE or MAiLiNG ADM3 R-E/7RI g g 6-kK imit‘i <br /> t <br />FAx # <br />( ) <br />CITY Miltin:g04— <br />STATE Z3$3 7 -7 <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: eka <br />PROPERTY / BUSINESS OW OPERATOR / AGER 0 OTHER AUTHORIZED AGENT 0 <br />If APPLICANT is not the BILLING P Y, 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 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: Reciii,`"Ir rood Rao diece_ vet) <br />CommENTs: SEP 2 0 <br />2022 <br />a4/41 JOAQii <br />NIRO IN °DU HEAL.rti 06-^ Np'AfEnirk. 7? <br />ARNENT <br />ACCEPTED BY: <br />V. <br /> pect raza EMPLOYEE #: DATE: <br />ASSIGNED TO: v . ep eci r a za EMPLOYEE #: DATE: <br />Date Service Completed (it already completed): SERvicE CODE: 50 3 <br />Payment Date <br />Received <br />el 12_01 2 z <br />13 1 E: / (0 0 1 <br />By: tiffAl <br />Fee Amount: 4 (p ig Amount Paid fit 1.1() IC(34----- <br />Payment Type 0, a Ad, Invoice # Check/ton& : IS-bi elaa <br />Ll <br />t5t,_ DATE: (7 <br />PA <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003