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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID # SERVICE REQUEST # <br /> Commercial � r '(,✓ S R \J (2) (87 4 �7 0 <br /> OWNER / OPERATOR <br /> AT &T Services CHECK if BILLING ADDRESS O <br /> FACILITY NAME <br /> AT&T UE020 <br /> SM <br /> West Elm Street Lodi 95240 <br /> lI 4 Street Number Direction Street Name City Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> SAME Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE #1 E)cT• APN # LAND USE APPLICATION # <br /> ( ) 4 3 - 0 36 - 0 <br /> PHONE #2 EXT• BOS DISTRICT LOCATION CODE <br /> c ) ® © 4 <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> Tim MCElhen CHECK if B��;% <br /> ILLING ADDRESS <br /> gSINESS NAME PHONE # EXT. <br /> ait Environmental Services ( 310 ) 997 - 5326 <br /> HOME or MAILING ADDRESS FAX # <br /> 701 Parkcenter Drive ( ) <br /> CITY Santa Ana STATE CA ZIP 92705 <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 : TtK*toth A * MoeLkevwU DATE : 11 / 17/ 23 <br /> PROPERTY / BUSINESS OWNER ❑ OPERATOR / MANAGER ❑ OTHER AUTHORIZED AGENT KI Project Manager <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 <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 : <br /> COMMENTS : / V <br /> SA N Nov ? 8 <br /> q ?423 <br /> IY40V/p NMENCUN Y <br /> EPq q � <br /> ACCEPTED BY: EMPLOYEE # : DATE : (/ N <br /> � ZJ <br /> ASSIGNED TO : j` EMPLOYEE # : DATE : <br /> Date Service Complete If already Com ted) : SERVICE CODE : le �22ef f �tP I E : <br /> Fee Amount : Amount Pai ,0U Payment Date ( � F �j <br /> SrU • <br /> Payment Type I Invoice # Check # 7z2-a/ /233 Receiv d By: <br /> EHD 48-02-025 SR FORM (Golden Rod ) <br /> REVISED 11 /17/2003 <br />