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DATE: <br />OTHER AUTHORIZED AGENT 0 <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />EST <br />TYPe of Business or Properly FACILITY ID # SERVICE REQUEST # <br />S F002-7 31(0 <br />OWNER i OPERA <br />"A' Ck S i ild 4 0 <br />CHECK If BILLING ADDRESS II <br />FACIUTY NAME <br />li! W kn. 1Y Uct_i LuL <br />SRE ADDRESS <br />Street Number Direction Street Hama Z • Cod" <br />NOME <br />MO <br />ADORESS rent t <br />a <br />Dife <br />Assiee <br />Sit. <br /> <br />d e ) <br />fr <br />ui <br /> t Number Street Nam* <br />CiTY -1-nc,t -t1Y'\ /4 STATE At <br />.11.0/4 <br />PHONE it • En. <br />—19C1A KO q -ta-OD <br />ARM # LAND USE APPLICATiON 0 <br />PHONE *2 Ell. <br />( ) <br />EMAIL BOS DISTRICT LOCATION CODE <br />kPERATOR / MANAGER <br />AL laws <br />CONTRACTOR / SERVICE REQUESTOR <br />REOUESTOR ?5\ful da sour& <br />MUMNESs NAMEThe Uitr u <br />HossEor MAKiNG ADDRESS c;r5-. k ) Lon ul <br />CITY <br />CA-OC <br /> STATE cr)-26 <br />CHECK I/ BILLING ADDRESS <br />PAIXTE1 Wq igT <br />FAX # <br />) <br />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 EnvinonmENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity <br />wit be billed to me or my business as identified on this form. <br />I also certify that I have prepared this application and t o be perf <br />ed will be done in accordance with all SAN JOAQUIN <br />Courny Ordinance Codes, StanØardsS ATE and FEDE <br />APPUCANT'S SIGNATURE: <br />PROPERTY! BUSINESS OWNER:11 <br />If APPLICANT is not the BILLING PARPt, 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 above sA‘, <br />address, hereby authorize the release of any and all results, geotechnical data and/or environmentaUsite assessment information tiAtn Iv ri °ENT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is provided to me °RECEIVED <br />representative. <br />TYPE OF SERVICE REQUESTED: itior /-e. Food 7; . G , CL P/4-1-4. CIL-CZ-4 OCT <br />COMMENTS: <br />I SAN JONoutt-te.• -flneko_ t)\aA, . „ ENVIER( CA <br />HEALTH E <br />N) bdt) A444 I e <br />ACCEPTED BY: 134,-‘0.44,44-4..... EMPLOYEE #: DATE: 104 7 /23 <br />ASSIGNED TO: .7 e er c . EMPLOYEE #: . <br />S .2. <br />Date <br />Date Service Completed Of already completed): SERVICE CODE: <br />DAT ,07/ 7/ 2... <br />Fee Amount: rittini-1-6944 7----- Amount Paid i4 -y c1 Payment I 0 ii 7.-- 2-4) 2,3 <br />Received By: 1:119-7 Payment Type C.44...zo L invoice # Check # <br />1? 2023 <br />UIN COUNTY <br />NMENTAL <br />EPARTMENT <br />EHD 4802-025 <br /> SR FORM (Golden Rod) <br />03/22/23