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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> F— SR®0 Scoa30 <br /> OWNER I OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME -g Kaur $k 5 18 <br /> SITE ADDRESS CA- A/Tr- � � S f of kTn Al <br /> Street Number Direction Street Name city Zip Code <br /> f�OME/ or MAILING ADDRESS (If Different from Site Address) �S C�l!� _ Street Number J Street Name <br /> CITY STATE ZIP <br /> PHONE t Exr. APN# LAND USE APPLICATION <br /> 306 - 3007 <br /> PHONE#2 ExT, SOS DISTRICTLOCATION CODE <br /> (20 ') 346 - 6,o-7 i <br /> CONTRACTOR / SERVICE REQUESTOR <br /> R:EQUESTOR � I`1 <br /> CHECK if BILLING ADDRESS <br /> BUSINESS NAMEPHONE# ExT. <br /> KO.IAr # 5V9 ( ( <br /> HOME or MAILING ADDRESS nn FAX# <br /> /f f ( ) <br /> CITY t4 jLZip q5,550 <br /> }'rte <br /> BILLING ACKNO 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 <br /> or activity will be billed to me or my business as identified on this forth. <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: / �� b-3 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT <br /> I"APPLICANT is not the BLLLiNG PARTY proof of authorization t0 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 environmentaUsite 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: i P t <br /> COMMENTS: 'WIC1 <br /> RECEIVED <br /> JAN <br /> 102023 <br /> JOq <br /> N EAIVIRptiM COUMTV <br /> ACCEPTED BY: S•� 1-\kw a rl l') EMPLOYEE#: DATE: '4RTMENI, <br /> ASSIGNED TO: 1 Ker EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: P/E: 'W O Q <br /> Fee Amount: Amount Paid SG,6� Payment Date / <br /> Payment Type C1� Invoice# Check# ��Jr�33 Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br /> ��0r52iO0gq <br />