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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />' Typeof Business or Property , i <br />C.- Ckt'C. V' t‘ Aj <br />FACILITY ID # SERVICE REQUEST # <br />SR002-1-458 <br />OWNER! OPERATOR <br />k e k- 14-01 <br />CHECK if BILLING ADDRESS <br />FACILITY NAME CI_ r <br /> <br />1' I e..--v- Reul Ca.4--e,r -, R. <br />SITE ADDRESS 3 ga <br />Street Number <br />is.1 <br />Direction <br />A t,l_rora. st <br />Street Name <br />ci'aoa <br />Zip Code <br />Si-ocK-i-ern <br />City <br />yom Site Address) <br />KlerA 0 tk_v-e Street Number _... Street Name <br />HOINE_prIAAILING ADDRESSA1 Different <br />q GO 5 73 <br />CITY _40 cli,(,\.., CT74 <br /> <br />ZIP ( <br />PHONE #1 Err. <br />00C1) 0 .3 — 9 TO K <br />APN # LAND USE APPLICATION # <br />PHONE #2 Err. <br />( ) <br />BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE RE UESTOR <br />RENEFOR, i <br />C K i`t 5-1-Opk 417-- _9 <br />CHECK if BILLING ADDRESS CHECK <br /> <br />Busss NAK V.ti <br /> <br />C-k-eF (13 6A4Cu- l' Al <br />PHONE <br />H71 1,7- rILING t IM: .SS <br />-11 ti )6-e0t CitV-e- <br />FAX # <br />( ) <br />CITY 5..... ct V 4_ci) \..., STATE' /4- ZIP CLQC,L i <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, STAT nd FEDERAL laws. <br />DATE: <br />PROPERTY / BUSINESS OWNEI OPERATOR / MANAGER 0 OTHER AUTHORIZED AGENT 0 <br />If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required <br /> <br />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 />orovided to me or my representative. <br />information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at tA same time it is <br />4 , . . <br />11(eCil i(V f' TYPE OF SERVICE REQUESTED: Caker iv1/ Consu \-A3A1D-1A I ke° <br />NOV COMMENTS: 9 <br />44/V Jrt . 4 l 2023 <br />11447444/R0/141 COO Pi Opz4101/ 7-4 ,47)• <br />ACCEPTED BY: "T. Ca r r tA es co EMPLOYEE #: 0 4 (.0 7 DATE: I - 0., I - 03 <br />ASSIGNED TO: <br />C• N4 ‘.'t r 0_ EMPLOYEE #: q gos DATE: 11 _ Os 1 _ 3 <br />Date Service Completed (if already completed): SERVICE CODE: 00 ) P I E: ju 02 <br />Fee Amount: I (.0 rnount Paid it2 R.--- Payment Date i i <br />Payment Type Invoice # -"661#; fT2 /VA 4 1D13 <br />Received By: <br />END 48-02-025 <br />REVISED 11/17/2003 <br />SR FORM (Golden Rod) <br />P‘CZ <br />APPLICANT'S SIGNATURE: --2-(