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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID# SERVICE REQUEST# uo 2WL-1 y SQ 00 9 Q) '2�'�- OWNER OPERATOR L 01�zu k1I* oG CHECK If BILLING ADDRESS❑ FACILITY NAME 1-4 COSDD� 4A H SITE ADDRESS U00 W ll an�Jt Cly .1C e-e� `1 'szo, ? Street Number Direction ✓ Street Name Cit Zip Code HOME Or MAILING ADDRESS (If Different from Site Address) g17� SS� 1 Street Number I'7l) Street Name CITY C�l/t/w t STATE /1A ZIP O`S��S PHONE#1 E"r• APN III LAND USE IAPPLICATION# Log&-- i q (10 PHONE#2 Em BOS DISTRICT LOCATION CODE ( ) CONTRACTOR / SERVICE REQUESTOR REQUESTOR f Y�11 C( SCC) L`im MAC n O _ \ vQ�� s rY �/� ,/� -7--A T�� i ILL 'I'Iti" r�u�� /CHEC7K if BILLING ADDRESS BUSINESS NAME —t A CQ/ IYI GI r I L AY1 i I I 0 �I" �1 PNnpr/I) `i, �j 1 I q'w Ezr HOME Or MAILING ADDRIE�SS LlJ PO (3� G 5^' 1 FA%'#D 1 `( �/ �T 1 ( ) CITY G)l�.0 STATE ZIP QI 5Z(D 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 Lhat the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes,Standards, STATE FED laws. /� 2 APPLICANT'S SIGNATURE: Z�2 DATE: PROPERTY/BUSINESS OWNER[] "OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ If APPLICANT is Not/he BILLING PARTY proof of authorization to sign is required Title 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 andsame time It is provided to me or my representative, 1 / �n f" M TYPE OF SERVICE REQUESTED: i OO �1 L9 vll( Vis L U-\- L IVP• COMMENTS: 0 I n/I I� ci � Iowa �C�� 14J,J N 2 0 2023 V`t/l l,� WVl1L H"'�Z Roll`V I'LL H DEpq�T,N NT ACCEPTED BY: X& EMPLOYEE#: DATE: b) ✓lu _�'1 ASSIGNED TO: I is EMPLOYEEM DATE: L Date Service Completed (if already completed): SERVICE CODE: P1 E: Fee Amount: I S Amount Pal l� OD I Payment Date Payment Typ Invoice# Check# — Receiv d By: EHD 48-02-025 SR FORM(Golden Rod) REVISED 11/1712003