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P fLo .s•-t --1 --11 <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property FACILITY ID # SERVICE REQUEST # <br />OWNER/OPERATOR Ii <br />[kr c vvii 1 )4 CHECK if BILLING ADDRESS <br />FACILITY NAME r 13 2-C v4 a <br />SITE ADDRESS <br />Street Number Direction Street Name City Zip Code <br />HOME or MAILING ADDRESS (If Diffetrent from Site Address) <br />t--ki 1'1 L,t) in cic Cii) ci _ Street Number Street Name <br />STATE ZIP CITY ---F c., <br />C H. , <br />PHONE #1 Err. <br />(Qb ) 6 /2.-- 6173 <br />APN# LAND USE APPLICATION # <br />PHONE #2 Err. <br />( ) <br />EMAIL BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR kiby00,7- , 51r) CHECK if BILLING ADDRESS <br />BUSINESS NAME ? IS 2._ c f)1./1_ PHONE # <br />(5/ D ) L n -5 <br />EXT. <br />HOME or MAILING ADDRESS <br />6 <br />FAX # <br />CITY \ <br />1 'Cc-NC v) <br />STATE (.4 ZIP ‘/S3 -2 -7 EMAIL ci'vl s Vt . MO- 61-11 e 6.1 t. <br />Title <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 />I also certify that I have prepared thi lication and that the work to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standard Si TEa d FEDERAL laws. ,..4s:::) <br />APPLICANT'S SIGNATURE: 11 <br /> <br />DATE: <br />PROPERTY / BUSINESS OWNER.. a OPERATOR / MANAGER 0 OTHER AUTHORIZED AGENT 0 <br />If APPLICANT IS not the BILLING PARTY, proof of authorization to sign is required <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 it is provided to me or my <br />representative. <br />TYPE KityigtRED: p ict,„ Check. <br />COMMEN <br />' P 22 <br />SAN JOAQUIN <br />El ED <br />202 <br />+...2 <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />COUNTY <br />ACCEPTED BY: — <br />\ <br />EMPLOYEE #: (0 ,24 3 DATE: <br />ASSIGNED TO: EMPLOYEE #: DATE: <br />Date Service Completed (if already com meted): SERVICE CODE: 5,3 <br />PIE: 1(001 <br />Fee Amount: $42(0 Amount Paid I 416 Payment Date Ci'2 <br />Payment Type Type C C_____ Invoice # Check # Received By: , <br />cfl k°1 2. 7 Li 5-82_ <br />EHD 48-02-025 <br /> <br />SR FORM (Golden Rod) <br />03/22/23