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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Properly FACILITY ID # Is SERIFICE REQUEST # <br /> OWNER / OPERATOR CWAff ®' <br /> Sal-r..�.�, �, • _ _ __. _ m <br /> FACLRY NAME 1741 <br /> SITE AmEss 2 �a2 6okn4vy [ t6 91vd �-ock �• q5 guy <br /> 8treer Number Dirsatten Sw •*i Nom. Cu Zi Cods <br /> HOME or MmNG ADORE'8s (if Different from Slee Address) <br /> sa«t Number e4est Nems <br /> ChTy STAT! LP <br /> PNONE61 Em APNIll LAND Us! APPLiCATION <br /> ( 77) $L9 ef74/ <br /> PME02 Exr. EMAIL 003DIeTPJ0T LOcATMoNCOVE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REO <br /> �YESTOR L CKzcn ifI <br /> Buswf M NAME + w �/j' ,� Romeo E"'• <br /> Ash onkHct .s.HC� ro7 <br /> HOME Or MAILING ADr7REs� , , <br /> ' 22 y rr . <br /> 3 •••r <br /> Cnti S4 O STAT! / ZIP fZ/LR2:5 ENAILr 4C4 l <br /> SILLIN� A�KNt�WL�� I, the undersigned property or business owner, operator or authorized agent of some, <br /> acknowledge that all she 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 /> 1 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, STV t and FEDERAL laws . <br /> APPLICAM 41MATURM C_- " DATE: Z► 3 <br /> PROPERTY I BUSINESS OWNER ❑ OPERAT3R / MANAGER ❑ OT HFR AUTHORIZED AGENT 0 vir, <br /> 1fAPP%xw 1A not the BILuNe PARTY. proof of authorizatlon to sign Is required T1r1e A <br /> 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 envlronmentel/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 /> — p <br /> TYPE OF SERVICE RE4UE8TED: <br /> - - - - YM <br /> l�oNe�ENTe: ' E ANT <br /> � VA <br /> N <br /> tiJ, Q�� ? 2023 <br /> E R CO <br /> ACCEPTED By: EMPLCYEEe #: DATE: p RNT JNT y <br /> q <br /> ASSKINlD TO: O t f'h EMPLOYEE M DATE: C51 2W43 T MFNT <br /> Date Service Completed (it already completed): SERV= CODE: ,�! '�' PIE: . <br /> Fee Amount: 1-1 VV Amount Pal LLI g �� Payment Date L <br /> Payment Type ��/j, , . Invoice # Check # f ( j 2 0ce <br /> a3 � Reived By: <br /> EHD 48-02425 SR FORM (Golden Rod) <br /> 09!22!23 <br />