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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID # SERVICE REQUEST # 51,(4 03 0 5.-q1 OWNER / OPERATOR vo\ ()Nt, T---.1cm.Q___ NoNet.--Pwe CHECK if BILLING ADDRESS FACILITY NAME 0\ oNi-ec aNc \-v\e__ 6-viAtz_ - Nce SITE ADDRESS CO StreeA umber Direction A- e3\ . Street Name gankelCk City ck q133-1.. Zip Code HOME or MAILING ADDRESS (If Different from Site Address) V 0 Street Number —1-7t VI 0-e_ sk • Street Name CITY fl5WV1-e771 STATE CA ZIP q PHONE #1 EXT. ( q 7-t-) '7"jef — -/-)c,C, APN # LAND USE APPLICATION # PHONE #2 EXT. ( ) BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE FtEQUESTOR REQUESTOR \-lk CHECK if BILLING ADDRESS BUSINESS NAME 1 LOVe-2, kjte,1% Coto uic\. P IN Eett 1 _ ( C.. )) EXT. , HOME Or MAILING ADDRESS (0 tr() Vek \ve_ (,)k • FAX # ( ) CITY 14 RIA\ e ( C-\ STATE ZIP CV:y.55V 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 applicatio d that t A o r to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, Standards, STATE d FEDE: .41:1101" r PROPERTY / BUSINESS OWNER 0 OPERATOR / MANAGER 0 HER 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 tlitgme time it is provided to me or my representative. TYPE OF SERVICE REQUESTED: -MOk ?1 avl ClaCk... - ICC/17%fr COMMENTS: t‘j eivu --raucV . 4f4R 3 1 1) 44414/n 1 2023 fitii V "OrAl CO PH t;I P4147.4/414' 441-4;1,4 cAlp ACCEPTED BY:IV\--- EMPLOYEE #: DATE: 31,3 I (2 ASSIGNED TO: ,,,14?.: v p EMPLOYEE #: DATE: Date Service Completed (if already completed): SERVICE CODE: P / E: 10 0 f Fee Amount: 41,, J-k t-6V — Amount Paid Kei . DO Payment Date Payment Type eXe-4/4- Invoice # Check # GI 733 s-,2 Received By: (R)---- APPLICANT'S SIGNATURE: 0-2) 1 -1-1 I 2 cv DATE: EHD 48-02-025 SR FORM (Golden Rod) REVISED 11/17/2003