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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or <br />5-ct,(Ay-a,r14.- <br />Property FACILITY ID # <br />FA:M=3'1-5-5 <br />SERVICE REQUEST # <br />rS9S1),CD <br />OWNER / OPERATOR <br />nhtx -66r) CHECK if BILLING ADDRESS Loh <br />, dik <br />FAciuTY NTin <br /> 6 W (711-rOt ri v,( frI I-Mi <br />SITE ADDRESS I a-t D Street Number \il Direction Tariner- Streerde 1---06i 1 City a5014cg— <br />Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />Street Number Street Name <br />CITY STATE ZIP <br />PHONE #1 Er-. <br />(g0/ 0.1P3 - 5/v1-15 <br />APN # LAND USE APPLICATION # <br />PHM2 so ..... 55 12.4 Err. <br />( <br />EMAIL • 6-titetvt6 la g Await con BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR LI 5helir6e/n i'Z' ill <br />CHECK if BILLING ADDRESS <br />.......-, • BUSINESS NAME srno Ailit, Air: vle, j.....ylt is...tvt ( PHONE # <br />(c9o9) <9&-3 6-&46- <br />Ex-r. <br />HOME or MAILING ADDRESS _-. . <br />1 0-1 0 kAf • ILA,rntr reA t-oA i OA qC060-- <br />FAX # ( ) <br />CITY STATE ZIP EmA'l-treeritiot&qriati <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 />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 la S. <br />APPLICANT'S SIGNATURE: LPL- DATE: /9-I /2o3 <br /> <br />PROPERTY / BUSINESS OWNER 151 OPERATOR / MANAGER 151 OTHER AUTHORIZED AGENT 0 <br />If APPLICANT is not the BILLING PARTY, 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 site <br />address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment t i formation to the <br /> <br />ItoSAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is prov. biArie or my <br />representative. & 1 <br />TYPE OF SERVICE REQUESTED: i l'\ CA (12 e ' 0 LAI n,e,r oce „ <br />COMMENTS: <br />I Y 2023 s'IN Jo, <br />I-JAivIR'QuIN c AL T , 9iv iviz...00N .7 ,_ <br />ACCEPTED BY: .r---- i7.44 i z_ EMPLOYEE #: DATE: 1 l//If /25 <br />ASSIGNED TO: _r, Pc, 7 EMPLOYEE #: DATE: /2 p 4//t •-, <br />Date Service Completed (if already completed): SERVICE CODE: iL PIE: N,2 0 L <br />Fee Amount: 1 /j. oC) Amount Pai0 / i Le. 2. DC) Payment Date <br />Payment Type Invoice # Check # /D6,3- Received By: <br />EHD 48-02-025 <br />03/22/23 <br />SR FORM (Golden Rod) <br />120 0 k4CCDI