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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property FACILITY ID # <br />'F-A000' ici 3?, <br />SERVICE REQUEST # <br />5 ROOS -7 -7- 5 <br />OWNER/OPERATOR <br />CHECK if BILLING ADDRESS V ii_ v <br />FACILITY NAME R 3 non c 0 ..e..cee Sop <br />SITE ADDRESS IS 1 <br />Street Number <br />c• <br />Direction <br />m a r \ poS3 Rct <br />IStreet Name <br />5+0c K -1--o-r \ <br />City <br />95 g 05 <br />Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />9 0 7,,6 AA U A CCO V CV IN" \di e-- Street Number Street Name <br />CITY C.4STATE ZIP <br />PHONE #1 EXT. ' APN# LAND USE APPLICATION # <br />PHONE #2 <br />ilo)c-k <br />EXT. 92-2 - 1-ck 6 cl • <br />EMAIL BOS <br />v.-cAlAcxc_01,--c--Q 5\,\0))41Ao-tittor) <br />DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR 4-7 \ <br />L.-- —k- O. V S \ W e( <br />CHECK if BILLING ADDRESS <br />( BUSINESS NAME p <br />,n ad') Co-C-c. Stlop PHONE # <br />( ) <br />EXT. <br />,-- .al-,(\.Q HOME or MAILING ADDRESS FAX aS a boNi e # <br />( ) <br />CITY STATE ZIP EMAIL <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 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: i;;(40.‘ 'SAO\ <br />PROPERTY / BUSINESS OWNER 0 OPERATOR / MANAGER 0 OTHER AUTHORIZED AGENT 0 <br />If APPLICANT IS not the BILLING PARTY, proof of authorization to sign is required <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\ any 04- ow ners hi p PAYmEm, <br />COMMENTS: RECE . " IVED <br />FEB 1 5 2024 SAN Ar, -vAQUIN c ,... <br />1.4%17.ViiiF2ISIMENUTAtilVIY <br />utpART l <br />DATE: 1 g, _ ACCEPTED By: sb EMPLOYEE #: <br />ASSIGNED TO: <br />C [V\ <br />EMPLOYEE #: DATE: 1 ,-a _._ 1 5 _ a 4 <br />Date Service Completed (if already completed): SERVICE CODE: 001 P /E: tu oa <br />Fee Amount: AS (D D. Amount Paid ,..1 cc 2 ;___- Payment Date <br />Payment Type caiid Invoice # .C.W. i ---fcr2 _1;5 92.c.t7i Received By: CO---2-(<' <br />EHD 48-02-025 <br /> SR FORM (Golden Rod) <br />03/22/23 <br />Wot vAG\001 <br />DATE: 0 Z 7/ 2c5z_v <br />Title