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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID # SERVICE REQUEST # N (-_-_--- OWNER / OPERATOR c.E-011 0 P.,0 ko T 7 E- , . CHECK if BILLING ADDRESS H D N T E IV FACILITY NAME \c-EpttZW41-19-7V4k7,- SITE ADDRESS rl Street Number Direction C t'S.1- LE- 5 7 Street Name C.)-r- C C- KIT i7t City cf 5 2.0 4 Zip Code HOME or MAILING ADDRESS (If Different from Site Address) 5 G T.+ Street Number C' .2 /-4:f `i Li P Vil nEti /AMEN .— - Street Name CITY S VG CV. TC,N STATE ZIP CA- 95 -Z1 9 PHONE #1 ( 109) Crb 1 .- 1.1561- EXT. APN # 4 2:540-0)- LAND USE APPLICATION # PHONE #2 ( ) Err. BOS DISTRICT c2 LOCATION CODE rA CONTRACTOR / SERVICE REQUESTOR REQUESTOR K ED 11 0 p) 0 V\ffi 4 T To. b.,._ CHECK if BILLING ADDRESS, BUSINESS NAME rku 1 .-.\--ZN PHONE # cm ) q g 1 - 1--(7) (.2 + Err. HOME?.7671.7 IkA))DITtN 5 P1IT N ko.11- Ty._ .4 4,4D FAx# ( ) CITY --TD C KTo N STATE ( k ZIP 95 2,11 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 an FED laws. DATE: PROPERTY / BUSINESS OVVNERIZIV 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 pitiosiir time it is provided to me or my representative. ENT -....‘, CiVED TYPE OF SERVICE REQUESTED: COMMENTS: OEC 0, I 2022 .0,1Q0A , =,--ARN6NT ACCEPTED BY: -Th . .,.. EMPLOYEE #: Co. Z 1 '3 DATE: 17".121 2_2_ ASSIGNED TO: /......k.f. dA... _ a OAk424 EMPLOYEE #: 1c81 .s DATE: ( jj z 2 2_ Date Service Co • leted (it already completed): SERVICE CoDE: - P1 E: 1 Of Fee Amount: 4--61( Amount Paid ziL6. Y. o D Payment Date 12/212:2 __ Payment Type (2_,k__ Invoice # Check # 13q1 Received BY:/,' APPLICANT'S SIGNATURE: .( / 02-722— EHD 48-02-025 SR FORM (Golden Rod) REVISED 11/17/2003