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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />I' areite,Y <br />FACILITY ID # SERVICE <br />SICOOC(LP-UL" <br />REQUEST # <br />OWNER! OPERATOR 1 , r-t ei , YI PL-.44- CHECK If BILLING ADDRESS <br />FACILITY NAME <br />(L-a-il-frn I VAtil -ey 14Cct -' Ain s <br />SITE ADDRESS -2_ 5 1 <br />Street Number <br />. <br />Vrtettrt A Street Name S. &NA (a Arvz. City ZIP Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />rt./ r - t, Stree Number —Ceirretterv,) co/ Street Name <br />CITY <br />9 '6°Ck;.6214 <br />STATE ZIP <br />PHONE #h EXT. <br />()_-o ll 1 C APN # LAND USE APPLICATION # <br />PHONE #2 Err. <br />( ) <br />BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR bec <br />c: <br />., ss, <br />,7 A iil ‘f / CA. CHECK if BILLING ADDRESS <br />BUSINESS NAME -I ifc <br />EXT. <br />HOME Of MAILING ADDRESS <br />154.1 <br />N <br />a % Y <br />En # ( ) Sk ci: TeX WOW° Cm, , ._,D STATE Pr, ZIP5c.----2,/ -2, <br />• <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 <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 Ordinance Codes, Standards, STATE and FEDERAL laws. <br />APPLICANT'S SIGNATURE: DATE: el/ At - <br />PROPERTY / BUSINESS OWNER rit OPERATOR / MANAGER El OTHER AUTHORIZED AGENT <br /> <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 <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 ENVIRONMENTAL 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 />COMMENTS: nn <br />olot ylciite-, <br />ki: n/ IciI0 <br />ra_g6a,Lty <br />A`t c 1 -Ngt- 0 e()? 17 V..41 0 <br />etvt-t-5 a q-ro <br />0 4,..e 0 i „c ps <br />e-e-y <br />y kyi ity <br />the.. <br />fr.., 6 <br />SAN <br />firgutiv*An <br />cefti3 <br />SEP 2? 2021 <br />joAoi I.. <br />ACCEPTED BY: cavvit g6 a0 EMPLOYEE #: DATER aiRth* <br />TY <br />ASSIGNED TO: .7f7fiNtseicot EMPLOYEE #: <br />M, <br />DATE: 9- -17, --2r, •• <br />Date Service Completed (If already completed): SERVICE CODE: <br />7(o / PIE: E: 76,11 <br />Fee Amount: IS 2._ , OD Amount Paid q),1 9 ..--- Payment Otte 91 2412, ) <br />Payment Type 0,31,,,y Invoice # telVis, L32 .3,2_2861-4 Received By eurlzr <br />END 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />2-,05351t 1