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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Skilled Nursing Facility r/A mW G-4-zZ <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> Deerarass Healthcare, I <br /> FACILITY NAME <br /> Fairmont Rehabilitation Hospital <br /> SITE ADDRESS S Fairmont Avenue Lodi 95240 <br /> 950 Street Number I Direction I Street Name City Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 29222 Rancho Viejo Road, Suite 127 <br /> attn: Licensing Street Number Street Name <br /> CITY STATE CA ZIP 92675 <br /> San Juan Capistrano l� <br /> PHONE#t ExT. APN# LAND USE APPLICATION# <br /> (209) 368-0693 <br /> PHONE#2 ExT. EMAIL BOS DISTRICT LOCATION CODE <br /> (949) 487-9500 renewaIsCcDensig nservices.net <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> HOME or MAILING ADDRESS FAX# <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 /> 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: DATE: 5/1/2024 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ® Treasurer <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 provi to me Or my <br /> representative. Q Y <br /> TYPE OF SERVICE REQUESTED: Change of Ownership - Food Permit rTtFCFS <br /> COMMENTS: MAY O <br /> SAN J /1 2 2�?�f <br /> EN Oq QU/N <br /> NEgL.TN�Sp�R��Ty <br /> T <br /> ACCEPTED BY:x7.44 LC(S C.C) EMPLOYEE#: DATE: <br /> ASSIGNED TO: ✓Gi i(�!S( (I EMPLOYEE#: DATE: Oslo-Z <br /> Date Service Completed (if already completed): SERVICE CODE: PI E: <br /> Fee Amount:' &Z OC Amount Pai f 2 OD Payment Date 2 <br /> Payment Type Ok t Invoice# Check# /,Ea77/J 4,I Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 03/22/230��� '30 C) <br />