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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FAWN ID# SERVICE REQUEST# <br /> Commercial /f 101961 S 9,0 m$7 4 7 0 <br /> OWNER/OPERATOR <br /> AT&T Services CHRMHOILUNGADOtME] <br /> $F�020 — <br /> 1 L4 OPINi - <br /> West Elm Street Lodi 95240 <br /> $[ro-el Hu�6or L_ ... 5ira:tN o CM1 <br /> HOME Or MAILINo ADDRESS pf Dwi&mnt tam sxe Addnm) <br /> SAME <br /> !-17-Y-- STATE zip <br /> PHOW#1APN# LAND U-se APPLICATION <br /> [PHOMKI#2Err, 808 On I ICT LooATION C0DE <br /> { - <br /> 0047ea _ <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQuEsToR <br /> Tim McElheny CHECK IF 1kUNJAPa=W <br /> f s NAME i <br /> PItoNE� <br /> V rev"! nmental Services _ rJ0 <br /> HOME or II��AILINfl AIDDREBs FAX 0 <br /> 701 Parl ter Drive { <br /> CrrY Santa Ana - STATE ZrCA 92705 <br /> ATTr.M ACIQ O EDGEtu>ri: I, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project <br /> or activity will be billed to me or my business as identified on this form. <br /> I also certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Onfinanae Codes,Slandards,STATE and FEWLAL laws. <br /> APPLICANT'S SIGNATURE: D DATx: 11/17/23 <br /> PkormnY/susu9R.ss0wx=[3 OPEIKATOR/MANAGER 0 OTHER AlTrHOW7ZDAGENT M _ ProiectMimager <br /> 4'APPLM0ffh no!1he$pkMPAgProof ofauthorlsadon to sign k required rflte-- <br /> AUTHORIZATION TO RELZME 29 MATION: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 BNMONMEIVTAL 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 /> COMM M: <br /> NOV?8 X13 <br /> $A Lr RoNMN coU <br /> �oEp ENrAc r <br /> ACCEPTED BY: EMPLOYEE* DATE: <br /> ASBIONEOT� f EMPLOYEEM. DATE: �� Z <br /> Data Service Compialed Ifalroady loo: BMWECON: PIE: UO <br /> ' Fee Amount: Amount Pa fC�r Payment Date v <br /> Payment Type f' Invoice# Check# <br /> S R e celv,:d By: <br /> EHD 48.02-026 SR FORM{Golden Rod} <br /> REVISED 11/1712008 <br />