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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST ? 30320 <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> A 0 0 1 t 9 SO 5ROO 8 4 35 <br /> �- OWNER/OPERATOR <br /> a r K r a S j n V, CHECK if BILLING ADDRESS <br /> FACILITY NAME G-bl-kmc"ArC e Cre a r>, PE -�E"-) a 8a I <br /> SITE ADDRESS 34. , Q ; n e r f� ve S+o C 1C i-'r� TqNsDo5 <br /> Street Number Direction M Street Name City Zip Code <br /> HOME or MAILING ADDRESS (if Different from Site Address) <br /> V/ VA+a.L. 10 C—Street Number J Street Name <br /> CITY <br /> S-}O K TV Y� C.4 zIP 9 10 <br /> PHONE#1 ExT• APN# LAND USE APPLICATION# <br /> ('�01) 95c0 - 0')Co193 <br /> PHONE#2 EXT. EMAIL BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR 1_ I,, <br /> a r K I Y'CL-+L 5 I 1 l �-f 1 LA- rY) OL*A— CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> h Lk ryA ck-" T C e C re a'n, S a S cl.Jb o v e <br /> HOME or MAILING ADDRESS FAX# <br /> CITY STATE ZIP 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 identified on this form. <br /> 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: �J�yKI/l ��a� DATE: Z/ <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required Title i <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: )A <br /> WIZ <br /> COMMENTS: NOV $ 2023 <br /> S NV1F?OJV N COV �, <br /> HEALTH DE 41ENPAR'rMENT <br /> ACCEPTED BY: �a(1 EMPLOYEE#: DATE: I l _ i ! _ 91 3 <br /> /� <br /> ASSIGNED TO: \ /1 �r O EMPLOYEE#: DATE: I - 1 (p -0'3 <br /> I1(n _0 <br /> Date Service Completed (if already completed): SERVICE CODE: (0 I P I E: 1(.IJ 0 D <br /> Fee Amount: I (0 a Amount Paid 1�fD Payment Date /(P 3 <br /> Payment TypeInvoice# Check# Receive By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 03/22/23 <br />