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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID # SERVICE REQUEST # SQ.CbCD81 \ aø OWNER! OPERATOR' ,, //A) grajc, 65) :j( CHECK if BILLING ADDRESS FACILITY NAME /30 j eh PG1 1 CO C cA C SITE ADDRESS ,..1 C,-,) L Street Number &-- Direction Pti i n ---i 1 Street Name 6 la 6, iv, City Zip Code HOME or MAILING ADDRESS (If Different from Site Address) 4 e me, tA. 5)-- Street Number Street Name CITY STATE ZIP 61-bco-br, c-, .1 el 51.76 S" PHONE #1 Exr. -2 /5 - C1,2 J 4. APN # LAND USE APPLICATION # PHONE #2 EXT. ( ) EMAIL BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR Clir - 9ot ti 6,5 i i k_s ,TY CHECK if BILLING ADDRESS BUSINESS NAME ,-2 1.61jC.' PCi ) en-1y G PHONE # 00 (i ) 715— EXT. HOME or MAILING ADDRESS .02 60) c Z--- /1'16 i r‘ 5 )-- Fax # I ) CITY STATE 4%?,0 4, EMAIL 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 that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, Standards, STATE and FEDERAL laws. APPLICANT'S SIGNATURE: C-1 „--cl I) ex-5 DATE: Of — 2:3 PROPERTY! BUSINESS OWNER OPERATOR / MANAGER 0 OTHER AUTHORIZED AGENT 0 If APPLICANT IS not the 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 and at the same time it is provided to me or my representative. TYPE OF SERVICE REQUESTED: F-D, PIRA c Vt..12_0(-- .1 MI lb • •N•l•IMIE 1M • RECEIVED COMMENTS: AUG 28 2023 SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT ACCEPTED BY: -e-x Ow\ Q M EMPLOYEE #: DATE: g\ zbtz -S ASSIGNED TO: J".e. c e C . EMPLOYEE #: DATE: EA 248 \ z -• Date Service Completed (if already completed): SERVIcE CODE: C32; PIE: RiOi 2.62713 By:/p" Fee Amount: * 1.1 g • _ Amount Paid 446 Le 1,---" Payment Date S leceived Payment Type e of, Invoice # 1.4 11t# ilk, ((plc! 2 2 DC; DAVIUIP NIT EHD 48-02-025 SR FORM (Golden Rod) 03/22/23