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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property TArrOb Shop FACILITY ID # c-- ,ThSERVICE W-00(10A REQUEST # - OWNER I OPERATOR CHECK if rA GU i l e)on BILLING ADDRESS Er FACILITY NAME 601 OG/‘ ( R1V la t CIA 5 j-() D I D SITE ADDRESS z_Lf Street Number Direction -1-th 5115ET Street Nam S3710 Zip Code 104C City HOME Of MAILING ADDRESS (If Different from Site Address) Street Number Street Name CITY STATE ZIP PHONE #1 Ex-r. (75.) 7-8cf —2-ci 52_ APN # LAND USE APPLICATION # PHONE #2 EXT. ( ) BOS DISTRICT LOCATION CODE CONTRACTOR I SERVICE REQUESTOR REQUESTOR -1) cce\ lik) t5oeN CHECK if BILLING ADDRESS BUSINESS NAME Color (-4-n1)(cl-to/Is c)TuDio PF140- ( ) Z ° 1 EXT. - 83V —5-3 2? HOME or MAILING ADDRESS FAx# 2,(-4 e 101L 1-1 , 5T 2_14c-7 , r N- I ( ) CITY STATE ZIP q c-5 7.-5k' BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as identified on this form. 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 COUNTY Ordinance Codes, Standards, S Tap d FEDERAL laws. APPLICANT'S SIGNATURE: DATE: la VZ Z— PROPERTY / BUSINESS OWNERg.....- OPERATOR / MANAGER El OTHER AUTHORIZED AGENT 0 If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. TYPE OF SERVICE REQUESTED: C o tsi u i -1-1. TA 0 tj - ,-2 I-1 1Z._6 ifteC. 8 11141t COMMENTS: lei VErt Lk PE8 9 a 0 4 2022 sAN j0,1 Emil QuIN co Htio. liovn,,&,„ uNr y r, NEN r ACCEPTED BY: c) L A r , 1 N M7- LLELL01- EMPLOYEE #: iii.75 DATE: 7e7 /I ASSIGNED TO: ./.) . (.410,st 6.1.4 EMPLOYEE #: 9 8 34. DATE: Date Service Completed (if already completed): SERVICE CODE: ;410%3 PIE: 0 6i Fee Amount: 5 36 Amount Paict7/6.040 0 Payment Date Payment Type ii,...t... Invoice # Check # .q 4/3..----0 , Received By: EHD 48-02-025 SR FORM (Golden Rod) 07/17/08