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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />Fr '90 rej)(r <br />FACILITY ID # SERVICE REQUEST # <br />SI2 VD8U0 I. <br />OWNER / OPERATOR <br />CHECK if BILLING ADDRESS A R kile? A g 1 I) N An:RI—Pm 2_1) ._s cw/W <br />FACILITY NAME <br />l' P r-HG2cf ) 1%-c c D Pz._, 2,10 <br />SITE ADDRESS i(, A 0 I <br />Street Number Direction <br />_C • .H , c r r 2 LP A_I i 2 )) <br />Street Name <br />28 -77-12or <br />City <br />1.-3C <br />Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) ig,5,2,1 <br />Street Number <br />r 0 ci--/e5 Tic< 4 7--. <br />Street Name <br />CITY STATE ZIP <br />TP P CV (0- <br />PHONE #1 #1 Err. <br />(100 )f ,4 <br />APN # LAND USE APPLICATION # <br />PHONE #2 .,xrE . <br />(e75 0 6 ,29, -3-6 0 .-- <br />EMAIL , <br />Rallik12_&-t;i-,.1_4;44-11)/10— <br />BOS DISTRICT LOCATION CODE <br />CONTRACTOR! SERVeCE—REQUESTOR <br />REQUESTOR . <br />to A R 1 ,. piclg f‘241/7,40 16.9 .5"/L, ,k.09 g CHECK if BILLING ADDRESS <br />BUSINESS NAME 06i 1- t-- 14.)) 4 5 <br />PHONE # <br />(1/0g) 11/C. '-- <br />Err. <br />/ _6-1/-i <br />HOME Or MAILING ADDRESS , A c-.... ), a ciTE-P 5‘ I Fax # <br />( ) <br />CITY „Tr ,, , y STATE ( p ZIP ..7 0 -.,3 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 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: 1(14 mar, S qh ei DATE: <br /> <br />PROPERTY! BUSINESS OWNER 0 OPERATOR! MANAGER 0 OTHER AUTHORIZED AGENT 0 <br />If APPLICANT /S not the BILLING PARTY, proof of authorization to sign is required <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. <br />TYPE OF SERVICE REQUESTED: PC.,---f—Q-•--\— (--) ,-._„ . ,-.1 nricni 1 <br />RFCEIVED <br />COMMENTS: <br />APR 1 7 2023 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />ACCEPTED BY: r7 1 .1 AD /w A Sc-e,--k-ci <br />EMPLOYEE #: 08 ,- DATE: C LI/t? he 2 -3 <br />ASSIGNED TO: ' Wee& - 2 - 41. EMPLOYEE #: 6 2/-3 DATE: (,.L//- /2e -z --- <br />Date Service Completed (if already completed): SERVICE CODE: I-5 z 3 p/E:/60/ <br />Fee Amount: ,7 1&8 Amount Paid i c/6, g_____ Payment Date <br />Payment Type V1 C? flk Invoice # 91)edic # 1 6, 6 6 -3 ,,,) -------i/ Received By: <br />Title <br />SR FORM (Golden Rod) EHD 48-02-025 <br />03/22/23