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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Pe and n Cn t co-s r4)C-�l L5 :�mm 8� IT <br /> OWNER/OPERATOR <br /> r CHECK If BILLING ADDRESS <br /> V"mck c-, CA� <br /> NA FACILITY E 1 S Uv1 ?j Z <br /> -V k_"-kV"�� �k zqv 0 42x u Yam+ �111a <br /> SITE ADDRESS \ICI k-310`Q—r � a'�UJL �r�L1,L�LY� Ct S O <br /> C Street Number Direction I Street Name —LyZi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 Exr. APN# LAND USE APPLICATION# <br /> (ZAUCA Z10 <br /> PHONE#2 ExT. EMAIL BOS DISTRICT LOCATION CODE <br /> ( ) fi U.Y-ira (ANIVI <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR �A <br /> �� �✓\yl/ CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# ExT. <br /> 0 <br /> HOME or MAILING ADDRESS FAX# <br /> L� �c; 2y-,Uj, Zvi Z ( ) <br /> CITY AIL <br /> s�CkA-cn ,pr STATE � ZIP G, S x 3 � kv\\NC�-I V\U- tk <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 /> 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 law <br /> APPLICANT'S SIGNATURE: DATE: '1-3 <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT IS not the BILLING PARTY,proof of authorization to sign is required Title <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 PA $me or my <br /> representative.TYPE OF SERVICE REQUESTED: 6 0,,) Av* Ita1l <br /> IofN REG <br /> COMMENTS: IA <br /> $AN JOAQUIN COUNTY <br /> He&IRONMENTAL <br /> 'lI DEPARTMENT <br /> ACCEPTED BY: vo C. EMPLOYEE#: Cf IS3 I DATE: ' /Z <br /> ASSIGNED TO: (I`L EMPLOYEE#: C'` DATE: L,/_) /L3 <br /> Date Service Completed (if already completed): SERVICE CODE: 061 PIE: 103 <br /> Fee Amount: JfP I Amount Paid # 2Z— Payment Date 7i <br /> Payment Type l 1� Invoice# 'CH"' # q Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 03/22/23 <br />