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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />, <br />1' i ..-; , A (r2t 0 -e_ 4-L),(42,1 l c, <br />FACILITY ID # <br />Ne W <br />SERVICE REQUEST # <br />l'r ROTIBGLII-G <br />OWNER / OFIERATOR ..1-- CHECK if M av 1 t:_-,c M C14 '‘ NA 2-- LA V F --0 S LI BILLING ADDRESS <br />,FACILITY NAME ____ <br />\ \ e v t'ot 0 f -Nct tv-i (-4 Yr <br />• :,I <br />) <br />SITE ADDRESS <br />1 06 .._... Street Number Direction <br />tc, v I c7t-) rot,. <br />Street Name <br />sVc,coo n <br />City Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />i 44 2...,-) U./ ct 40 5 _ Street Number (t 11 ' Street Name <br />Crry STATE ZIP <br />PHONE #1 Exr. <br />a,- ( 2 '1 5C R- 3 3S <br />APN # <br />i yi oso3R <br />LAND USE APPLICATION # <br />PHONE #2 Err. <br />( ) <br />BOS DISTRICT I LOCATIO1ODE <br />S tO4 tO )1 <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR " <br />rl c‘ v t (-pc k 14 ci v i 0. e z <br />CHECK if BILLING ADDRESS <br />BUSINESS NAME <br />V 1 r, v i: c•,. st) 0 v---- \ LI NV ot v ' )1 <br />PHONE # <br />( 1 <br />EXT. <br />HOME or MAILING ADDRESS <br />1 &i 2,C) 'W a ,ik,)-:(-- 5 A <br />FAX # <br />( ) <br />Cry .--\(..kcx... or\ c, v\STATE ZIP , c i 5 <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 <br />or activity 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 SIGNATUR r‘ as, (0,k c. v A "C. DAT 0 3 - 0 — <br />PROPERTY / BUSINESS OWNER OPERATOR / MANAGER 0 OTIIER AUTHORIZED AGENT 0 <br /> <br />If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required Title <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, 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 environmental/site assessment <br />information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTII 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: PAYMENT <br />COMMENTS: RECEIVED <br />C-OCNW\ -S.5(;( ' i 2-1 ‘ 5 -7 MAR 09 2023 <br />IN\ OckEDS4 <br /> <br />SAN JOAQUIN N COUNTY <br />ENVIRONMENTAL <br /> <br />.H <br />EALTHDEPARTo NT <br />ACCEPTED BY: - <br />, <br />EMPLOYEE #: Cis 243 DATE: 3 1 Gi I 2-3 <br />ASSIGNED TO: (-F6 e,( 04.4t,fyio A EMPLOYEE #: DATE: (EN ( 1 Z__3 <br />Date Service Completed (if .already coit\ pleted): SERVICE CODE: 2_3 P)E. <br />(kl.Fee Amount: Amount Paid i (/ --- Payment Payment Date I 4-1 ."....0 <br />Payment Type V/ )4— nvoice # C.hea # / s---vig6 c/ ?o Received By: ftyly <br />EHD 48-02-025 <br /> SR FORM (Golden Rod) <br />REVISED 11/17/2003