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PRO S 05--52 <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 'FaTa)m(DR-j q sRmmS--5-48 <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS® <br /> FACN.ITY NAME 'P—�i KK Cl1 r- - V� I L- � C o, <br /> SITE ADDRESSAv <br /> � �C M JOIC�37t)( <br /> Street Number Dk�on �streetName � `CLM C� Zip Code <br /> HOME or <br /> M/A'ILING AnnRFCC ns nircoront from Site Address) M�/1�\�� <br /> a� l/lX a— "v Street Number ���� SVeet N�me <br /> CITY n „ C� STATE ZIP <br /> v` CAcjJ�J ' <br /> PHONE#9 ExT. APN# LAND USE APPLICATION# <br /> ) vl Jam" cA; :D-5 <br /> PHONE#2 ExT. EMAIL BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# ExT. <br /> K G 2cq - CI a 6 <br /> HOME or MAILING ADDRESS^. FAx# <br /> CITY STATE ZIP EMAI <br /> a ce-o, CA 95'�3� �clArfcl� c A�� <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: DATE: IZ L--X-1 J5t3 <br /> PROPERTY/BUSINESS OWNER OPERATO /MANAGER ❑ OTHER AUTHORIZED AGENT [3 <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 provided to me or my <br /> representative. I� <br /> TYPE OFSERVICEREQUESTED: ChUOgQ US 0W0eVSht9 PAYMENT <br /> COMMENTS: <br /> DEC 2 9 2023 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE M DATE: IZ 'Z('I 12 <br /> ASSIGNED TO: �'� ' EMPLOYEE M DATE:1-2, 2ci''Z� <br /> Date Service Completed (if already completed): SERVICE CODE:(Q 0P I E: <br /> Fee Amount:$U%Z .(jm Amount Paid Payment Date 020 ZZ) <br /> Payment Type ! Invoice# 5be # 1 973-r) Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 03/22/23 <br />