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<br />DATE: <br /> <br />OPERATOR! MANAGER 0 OTHER AUTHORIZED AGENT 0 <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Propert <br />Q.. - <br />FACILITY ID # <br />OD 24 2.30 <br />SERVICE REQUEST # <br />SR_OOT-1(0 4 .7 <br />OWNER/OPERATOR 1 <br />CHECK if BILLING ADDRESS <br />FACILITY NAME .f. ks.,et de-' <br />SITE ADDRESS,3 of <br />-"sew 'Limber Direction <br />14)7 2-‘, <br />Street Name C71-0-&01-1-` City 7 z,5-c4,d--C <br />HOME Or MAILING ADDRESS (If Different from Site Address) <br />_.; 36 Street Number ._ 44147160 11 Stret4 Name <br />STATE ZIP CITY AI 6.101) <br /> VI <br />PHONE #1 Da. <br />r2C 9 7? 7- 301 0 <br />APN # LAND USE APPLICATION # <br />PHONE #2 EXT.EMAIL <br />( ) <br />g t <br />fe_rriGoAd D "Aa a rfnzliM. <br />BOS DISTRICT <br />cphat,t co <br />LOCATION CODE <br />CONTRACTOR / SERVICE RE UESTO <br />REQUESTOR <br />CA-fitE <br />CHECK if BILLING ADDRESS <br />BUSINESS NAME PHONE # <br />( ) <br />EXT. <br />HOME or MAILING ADDRESS FAX # <br />( ) <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 />I also certify that I have prepared this • .cation and that the work to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standar. , STK/ Ertd-FEDERAL la s.1 <br />APPLICANT'S SIGNATURE: K.' /-2,s/2-1 <br />PROPERTY! BUSINESS OWNE <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/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:(-- -1---mA RECEIVED <br />COMMENTS: eartruSEIA- JAN 1 3 2024 , <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />(-- ACCEPTED BY:EMPLOYEE <br />. <br />V '.. #: co <br />ASSIGNED TO: attikeLta--- q_OLM,-- <br />EMPLOYEE #: 9 7 2_9 <br />DATE: t [ 2.3 /7 <br />DATE: <br />iE: <br />F <br />/ Date Service Completed (if already completed): SERVICE CODE: 1,602,_ <br />Fee Amount: Lc Amount Paid •k / ... Payment Date <br />/ <br />Payment Type vzz, Invoice # ght(c-Ic # / lil-S- 3 r:,ci L/c7 — Received By: <br />EHD 48-02-025 <br />03/22/23 <br />SR FORM (Golden Rod) <br />?2053-1.Sto