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APPLICANT'S SIGNATURE: <br />PROPERTY / BUSINESS OWNER El <br />13 , ;13 <br />PE ATOR / MANAGER 0 OTHER AUTHORIZED AcENTE1 DE-% I 41-1 <br />DATE: <br />0-12 (0S0 <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />2 V STA 0 2-. A t`.1 T 1-- <br />• FACILITY ID # <br />-- A ()02_1 /41 S 5-7 <br />1 SERVICE REQUEST # <br />SQ.0180G kc-k <br />OWNER/OPERATOR <br />yk AF_v_. A*,vA-12---1 CHECK if BILLING ADDRESS <br />FACILITY NAME C-1 10 i&A 'S 0 'I--LA 12-4NM <br />SITE ADDRESS 3.100 <br />Street Number Direction <br />\ - 1 A-60--E----- <br />Street Name <br />12--D ‘1?--Acti--( <br />City <br />CA930Zt <br />Zip Code <br />HOME Or MAILING ADDRESS (If Different from Site Address) --• 4. ci <br />Street Number <br />t3 R-A A-1-1 ti e <br />Street Name <br />CITY 17 t,5;pc.SAct,1•11) \..1 STATE c/A ZIP 9 45 co <br />PHONE #1 Err. <br />(510 ) Vi- 06 9 <br />APN if LAND USE APPLICATION if <br />PHONE #2 EXT. <br />( I <br />BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR \,) ci., /es.Liv...--V 0 CHECK if BILLING ADDRESS a <br />BUSINESS NAME t."- ALA c‘.cc) 0 D 5 ( 1.2( ks.,...) Gyu Di c PHONE <br />(916) <br />EXT. <br />Piol- GLIT1- <br />HOME or MAILING ADDRESS 1 3 c, t+ pNli-v/11, -.--- <br />FAX # <br />( ) <br />CITY OA-K- L-A-11 D STATE Cie\ ZIP 94 b 0 1 <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, ST TE an FE a RAL law <br />If APPLICANT is not thc BIL ING PARTY, proof of authorization to sign is required Title <br />AUTHORIZATION TO RELEASE FORMATION: 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 />rAYNItN I <br />RECEIVED <br />COMMENTS: electronic APR 1 7 2023 <br />SAN JOAQUIN COUNT% <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />ACCEPTED BY: Vidal Pedraza EMPLOYEE #: 6213 DATE: 4-13-23 <br />ASSIGNED To: Kadeanne Linhares EMPLOYEE #: 4589 DATE: 4-13-23 <br />Date Service Completed (if already completed): SERVICE CODE: 523 PIE: 1601 <br />Fee Amount: 468 Amount Paid 1 c ----- u Payment Date 1 io <br />Payment Type Type /&, # Invoice # 9ertic # Received By: <br />Payment 160329956 ci/14)