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-- Type of Business or Property <br />Distribution Center <br />OWNER OPERATOR <br />FAckrry NAME <br />CHECK if BILLING ADDRESS Army Air Force Exchange <br />AAFES - Army Air Force Exchange Service <br />Street Number Street Name <br />LOCATION CODE En. <br />E XT. APN # <br />EMAIL <br />LAND USE APPLICATION # <br />BOS DISTRICT <br /> <br />SITE ADDRESS 700 , Bld g 550 E <br /> <br />Street Number Direction j <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />95231 <br />zi, Code <br />French Camp <br />CHv <br />STATE ZIP Dry <br />PHONE #1 <br />( ) <br />PHONE #2 <br />( <br />Roth Road <br />Street Name <br />FACILITY IR # (N s <br />CERS ID # 10187011 <br />SERVICE REQUEST # <br />S <br />CHECK if BILLING ADDRESSO <br />REQUESTOR John Brown <br />En. PHONE # <br />( 209 ) <br />Fax # <br />( 1 <br />234-3789 <br />1 BUSINESS NAME AAFES <br />HOME or MAILING ADDRESS <br />700 E Roth Rd, Bldg 550 <br />Crry French Camp STATE CA ZIP 95231 EMAIL brownjohn1@aafes.com <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />CONTRACTOR / SERVICE REQUESTOR <br />BILLING ACKNOWLEDGEMENT: I, the undersigned roperty or business owner, operator or authorized agent of same, <br />acknowledge that all site and/or project specific ENviRwkNTAL EALTH DEPARTMENT hourly charges associated with this project or activity <br />will be billed to me or my business as identified on tnis form. <br />I also certify that I have prepared this application and ittrer e work to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards, STATE and F ERA ,aws. <br />APPLICANT'S SIGNATURE: <br />DATE: <br /> 9/28/23 <br />PROPERTY /BUSINESS OWNER El opE6AToRr MANAGER gi OTHER AUTHORIZED AGENT 0 Facility Mgr II <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 above site <br />address, hereby authorize the release of any and all results, geotechnical data and/or environmental/siterQs.sessment information to the <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same vAymeirr to me Or my <br />representative. <br />--•-y—r ',LA., <br />TYPE OF SERVICE REQUESTED: \---\ "C"C\ (C. KZ...S c_s:30‘1\-s•-\\-4:,e•N <br />O.; I COMMENTS: 0 6 2023 <br />\A‘C\CVS . /C G QS cz)-(\s,.--\4-kcArN SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />ACCEPTED BY: EMPLOYEE #: DATE: <br />ASSIGNED TO: ‘-i 6, -L6., ,.... c,.._.c._ e__ 8. #: (z) EMPLOYEE ,-.8ricyncr DATE: v.y <br />Date Service Completed (If already completed): SERVICE CODE: PIE: \ 'D‘Q a_ <br />Fee Amount: 4 \ ,.., "a. Amount Paid Payment Date 0/1,7.2, ? <br />Payment Type C (____ Invoice # Check # Received By: <br />Cori <br /> <br />17000 2,971 <br />EHD 48-02-025 <br /> SR FORM (Golden Rod) <br />03/22/23