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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR 1,T <br /> I V % { V1/JOr I CHECK If BILLING ADDRESS El <br /> FACILITY NAME La Pe r//_ /Y— V1' <br /> 1�J <br /> SITE ADDRESS IO '_! Y✓ �M%/-7 J/- OK7 Le <br /> Stmel Number Dlrectlan Street Name CII ZI otle <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> 1 D P& Street Number Street Name <br /> CIN /J)n STATE zip <br /> l vw °l S3CQ(p <br /> PHONE#I ) EXT, APN# <br /> ( 2C�1) 0f 5 -6-10-7`-1O� LAND USE APPLICATION# <br /> PHONE(#2 LJ Ex. SOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDREeSri <br /> BUSINESS NAME PHONE# EXT, <br /> HOME Or MAILING ADDRESS FAX# <br /> CITY STATE ZIP <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 /> APPLICANT'S SIGNATURE/: / DATE: y2-Z_ <br /> PROPERTY/BUSINESS OWNERSyOPLf TOR/MANAGER OTHER AUTt10RIZED AGENT❑ <br /> /f APPLicAATisnOtthe BiLLrNc PA27r proof ofaurhorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1,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 t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the Same lime it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: RECEIVED D <br /> COMMENTS: P electronic MAY 0 2 2022 ECFzI 1%1, <br /> HA N JOAQUIN COUNTY <br /> ENVIHUE.RTGL "�,1,ilegNMEN <br /> HFALIII UCO/RiMENr .,I n�111 fNRTMEN <br /> .,Ii1M)I)IN CDA <br /> ut"NrdkNTL <br /> AE <br /> nt PAHI'AENf <br /> ACCEPTED BY: Vidal Pedraza EMPLOYEE#: 6213 DATE' 5/2/22 <br /> ASSIGNEDTO: Glgl Fahmy EMPLOYEE#: 8788 DATE: <br /> 5/2/22 <br /> Date Service Completed If already completed): SERVICE CODE: p I E' 1601 <br /> Fee Amount: 456 Amount Pal Payment Date y 2_ <br /> Payment Typo Invoice# CJmd# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 Payment confirmation 142656261 �����2..2— <br />