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P2o9 <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST#Q <br /> so eer bb 0o2-0 l7 D 0 2- S R O Q) T T O <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS❑ <br /> michael sneer <br /> FACILITY NAME <br /> tracy ciolf and country club <br /> SITE ADDRESS <br /> Street Number Direction $, CHRISMAN RD. Street Name TRACY City 95371P Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> 22792 COZY COURT Street Number Street Name <br /> CITY STATE zip <br /> TRACY CA. 95304 <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> ( 209) 321 0934 <br /> PHONE#2 ExT. EMAIL BOS DISTRICT LOCATION CODE <br /> ( 209) 855 1601 info@soeerbba.com <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT• <br /> HOME or MAILING ADDRESS FAX# <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 /> 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: michael speer DATE: 3/19/2024 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT is not the BILLING PARTY Proof of authorization to sign is required 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 prCNiC (1 to me or my <br /> representative. �Y/� <br /> TYPE OF SERVICE REQUESTED: EI V <br /> COMMENTS: <br /> SN Jo R 19 <br /> A ?014 <br /> HEALTH p ME Oq�TY <br /> T MENT <br /> ACCEPTED BY: �< L EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: S Qv Q DATE: 3 1 C71 , 2 H <br /> Date Service Completed (if already completed): SERVICE CODE: �- i,' I PIE: 1_10 ( 2- <br /> Fee Amount: b 2— Amount Paid b 2 _ Payment Date 3 ` o` 2- <br /> Payment Type CC Invoice# Check# 178 3Sg,g Received By: <br /> EHD 48-02-025 U SR FORM(Golden Rod) <br /> 03/22/23 <br /> S <br />