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DATE: <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property FACILITY ID # <br />FA 0 -0011 02 <br />SERVICE REQUEST # <br />SR00 S -7 b S 5 <br />OWNER! OPERATOR <br />CHECK if BILLING ADDRESS L PA ot-864-e -k- Li t_ <br />FAcILITY NAME TrOCeri 01A-11e+ C <br />SITE ADDRESS <br />10100 Street Number Direction At ;fleet Name <br />,--, <br />Code Zip Code <br />HOME Or MAILING ADDRESS (If Differpnt from Site Address) <br />u cf,- Q-k Street Number Street Name <br />CITY STAI,E.„ ._ _., ZIP <br />PHONE #1 EXT. <br />( LA <br />APN # LAND USE APPLICATION <br />PHONE #2 EXT. <br />( 501 (-Ng- t, <br />EMAIL , <br />TS L kvkiv-K-e-kS A.- cgo.ck.,J <br />BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR CHECK if BILLING ADDRESS El <br />BUSINESS NAME . PHONE # EXT. <br />( e_0,0 <log g frq 7 <br />HOME or MAILING ADDRESS <br />---) 00 NiAA.V \--V L.e)- QA <br />FAX # <br />( ) <br />CITY <br />(172)Nik 1-1-, ND kfi- -C <br />STATE civ\ ZIP q -s s co 1 EMAIL <br />7S L. Kroti4eA S d. 9( <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 activity <br />will be billed to me or my business as identified on this form. <br />I also certify that I have prepared this applic tion and that the _work to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards, STATE nd F: ALw.— <br />APPLICANT'S SIGNATURE: <br />PROPERTY! BUSINESS OWNER OPERATOR! MANAGER 0 OTHER AUTHORIZED AGENT 0 <br /> <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 site <br />address, hereby authorize the release of any and all results, geotechnical data and/or environmental/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 Of my <br />representative. <br />TYPE OF SERVICE REQUESTED: CI\ 0_,(Ay of ow vLeA.3hi F RECEIVED <br />COMMENTS: FEB 0 5 2024 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />ACCEPTED BY: Cik _ EMPLOYEE #: 0 4(0 7 DATE: <br />ASSIGNED TO: M a re, EMPLOYEE #: Ci S Q 2 DATE: -2. ---5-,—.2,t <br />Date Service Completed (if already completed): SERVICE CODE: 0 69 I i P 17 1 (0 Ci <br />Fee Amount: Avi ,a Amount Paid .# 4 ,.2 Payment Date <br />Payment Type -1 I C.. 4_ Invoice # 3k # N- 0/ g- 6/2_— Received By: <br />END 48-02-025 SR FORM (Golden Rod) <br />03/22/23 <br />12g 0 N) mos