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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property <br /> ----- FACILITY ID if SERVICE REQUEST 0 <br /> OWNER!OPERATOR CxEcx If( &6LtI G ADDRESS07 <br /> (,{yL_r I t11 l(I t Z _ _...�.. <br /> FACrLITY—NAME <br /> �57�� <br /> SRE ADDRESS <br /> wiL t#"Yt7 jL1lL' .£c'fa <br /> Strut Numt»r Grrctton SU"t Name CI ZI Code <br /> HOME or MAILING,ADDRESS of Different from Site Address) <br /> Steel Numar 5trIet Name ff r <br /> CITY ----- -. ... STATE (1 ZIP r��j/(,' �f <br /> PNDNE OM ExT APN a LAND USE APPLICATION a <br /> (a i ) 1 '7--7 U (1' <br /> PHONE II? EAT EMAIL SOS DISTRICT LOCATION CODE <br /> I I <br /> CONTRACTOR /SERVICE REQUESTOR <br /> REQUESTOR CHEcrc if BILuNG ADDRESS❑ <br /> BUSINESS NAME t�• a l �t f!X LtC PHONEX / ,` EXT. <br /> V � • 1971 3 20 <br /> HOME or MAILING ADDRESS 3�'I <br /> � 1 FAx <br /> _t ��rytit� . �`tr t 1 q <br /> CITY (lru^ p,.\�3 �� STATE '� z!P 1-1L1,�! t=MAILL� ��LtJ / �i1 1Je._A 5 . <br /> BILLING ACKNOY&EDGEMENT: 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 tome 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. Sfanderds,STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY I BUSINESS OWNER R OPERATOR I MANAGER ❑ OTHER AUTHORIZED AGENT Q <br /> if APPi1CANT IS NDf the 49ILONG PARTY,proof of authorization to sign Is required Tirle <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 environmenta!lsite assessment information to the <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It is available and at the same time it is provideAtq me or my <br /> representative __ / Jq= T <br /> Tyn of SERviCE REQUESTED: <br /> AZ <br /> COMMENTS: catering application review MAY 29 <br /> SAIy Jo 2024 <br /> kEp ty pq� ��N <br /> AccEPTEDBy: Vida! Pedraza EMPLOYEE10: 6213 DATE: 5.29_24 <br /> ASSIGNED TO. Gehane Fahmy —— EMPLOYEE#: 8788 DATE: 5-29-24 <br /> Date Service Completed (if already completed): SERVICE CODF: 61 PIE: 1602 <br /> Fee Amount: 162 Amount Pat 2 �� Payment Date S 2-1 ?� <br /> Payment Type + -54 Invoice 0 Check ar f82 f.-)_+5t+7 Recelve By: <br /> 611&— <br /> EHD 4"2-025 Payment 182124547 SR FORM(Golden Rod) <br /> 03/22/23 <br />