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?3k p 1 .kr) So-c- Co <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />['Type of Business or Property <br />t---(--) — <br />FACILITY ID # SERVICE REQUEST # <br />OWNER/OPERATOR <br />(:7 CN ( \ , :_rk € CHECK if BILLING ADDRESS --) <br />Facit.rry NAME \ <br />\ <br />SITE ADDRESS --v-2D0 <br />Street Number <br />-----) <br />Direction <br />CO\ \ ---C>(-\(-\\.0 `.1\-------C\--Y--IC Street Name City <br />C7\..", 203 <br />Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) 113.:)- <br />Street Number <br />1(N . \-\ --) cA 9 Sec . 7 y <br />Street Name <br />CITY STATE c A ZIP <br />PHONE #1 EXT. <br />r7CA\ <br />APN # LAND USE APPLICATION # <br />PHONE #2 Err. <br />( ) <br />EMAIL BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR CHECK if BILLING ADDRESS <br />BUSINESS NAME PHONE # <br />( ) <br />Err. <br />Home or MAILING ADDRESS Fax # <br />( ) <br />CITY STATE ZIP EMAIL <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 />I also certify that I have prepared this ajp-Pirc-Z-)-1--1 nd that the work to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards, STATE-a -lE A <br />• <br />APPLICANT'S SIGNATURE: DATE: - <br />PROPERTY! BUSINESS OWNER b PERATOR / MANAGER a jOTHER AUTHORIZED AGENT 0 <br />If APPLICAN <br />AUTHORIZATION TO RELAS FORMATION: 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. <br />TYPE OF SERVICE REQUESTED: C \C\ cr\(\s2 c% 0,....,s2...._2 j, -,f) Ree"LVIeNr <br />COMMENTS: teci <br />AfAr 15 , <br />SAN jn, 423 <br />„,..ENITp9,y_IN cal , ,_ <br />""1-771 crItfeiv741771- <br />r <br />ACCEPTED BY: L'-\ \(--0\,-.._9-z_ EMPLOYEE #: DATE: 'S---- I - 2 Z <br />EMPLOYEE #: DATE: ASSIGNED TO: ----\-- vf.-7- 0 <br />Date Service Completed (if already completed): SERVICE CODE: eV...L.)." IQ) i PIE: ',ok <br />Fee Amount: 1 S l() Amount Paid <br />( 1--(_P C--- <br />Payment Date I (2 3 <br />Payment Type () i6t3 )1 Invoice # Check # Received By: ax-y <br />BILLING PARTY, proof of authorization to sign is required <br /> <br />Title <br />EHD 48-02-025 <br /> SR FORM (Golden Rod) <br />03/22/23