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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />t10101te FOOcl 7 rU C-X-- <br />FACILITY ID # SERVICE REQUEST # <br />10 SP008 -i34(. <br />OWNER! OPERATOR <br />CHECK if L. u s e . 1.2.c.tv-r-v \ rr.7_ BILUNG ADDRESS <br />FACILITY NAME <br />-TO% CO C- ( 050 <br />SITE ADDRESS <br />Street Number Direction Street Name City ZIP Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />Street Number Street Name <br />Cirr STATE ZIP <br />PHONE #1 Eta. <br />(2.061) 4 ao - 3 q5 7 <br />APN # LAND USE APPUCATION # <br />PHONE #2 EXT. <br />(2o4 410:30 - g k) 05 <br />BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />Lt.) i..s- E • V. CA rn \ r t ,7_ <br />CHECK if BILLING ADDRESS <br />BUSINESS NAME <br />TcAco 1 ic ( 050 <br />PHONE # <br />( ) <br />Err. <br />HOME or MAIUNG ADDRESS <br />Li LI .Z. L 0.• SCTAte S 4- <br />FAX # <br />( ) <br />CITY <br />(A) ooci bridcle. STATE C-Pc ZIP ,--- -157,3 r <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 <br />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, STATE and FEDERAL laws. <br />APPLICANT'S SIGNATURE: <br />DATE: <br />PROPERTY! BUSINESS OWNER Er OPERATOR / MANAGER 0 OTHER AUTHORIZED AGENT 0 <br />If APPLICANT is not the BILLING PARTY proof of authorization to sign is required <br />Title <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the above <br />site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information <br />to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is provided to me Of <br />my representative. <br />TYPE OF SERVICE REQUESTED: I Ck f) ke:\O 1 e_.,..-) (--0 ; 1\A cAD , 1 e FLIC_>C1 TY CALL PAYMENT <br />COMMENTS: RECEIVED <br />OCT 2 6 2023 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />ACCEPTED BY: 'ES ,( ', cl n ne (kA EMPLOYEE #: DATE: ‘ (b \ l( 13 <br />ASSIGNED TO: \I , cx ca (D EMPLOYEE #: DATE: (LA 2(c.\ 2:3., <br />Date Service Completed (if already completed): SERVICE CODE: L3 2.7) PIE: too) \ <br />Fee Amount: 14,66 cr& Amount Paid 4 g ar,_ Payment Date 1 P IA" 4.0 2. <br />Payment Type V 15 pt Invoice # ,14tck # (--4-0 ctqs-- 1 Ot Received By: <br />EHD 48-02-025 <br /> SR FORM (Golden Rod) <br />07/17/08