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PHONE #1 <br /> <br />Err. 1 APN # LAND USE APPLICATION # <br /> <br />STATE ZIP <br />BUSINESS NAME <br />tA 1.136 <br />HOME Or MAILING ADDRE <br />SS531 3 A) cot Ic 9- / ç Porn <br />potCtiv..L <br />Crry <br /> DATE: <br />OTHER AUTHORIZED AGENT 0 <br />if APPLICANT is not the BILLING PARTY proof of authorization to sign is required Title <br />APPLICANT'S SIGNATURE: <br />PROPERTY / BUSINESS OWNER': OPERATO / MANAGER <br />Toikois83 <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />ype of Business or Property <br />(4i5 Ettid-t <br />OWNER! OPERATOR <br /> <br />FACILITY ID # <br /> <br />SERVICE REQUEST # <br />(I -2_ <br /> <br />CHECK if BILLING ADDRESS EJ <br />S 1110 ;3 Street Name <br />Street Number 1 Street Name <br />Mo trAV <br />BOS DISTRICT <br />HOME Or MAILING ADDRESS (If Different from Site Address) <br />FACILITY NAME <br />SITE ADDRESS <br />I-1 el <br />PHONE #2 <br />) <br /> <br />t tiC I t LC <br /> <br />IStreet Number Direction <br />ExT. <br />Ct C 331- <br />ip Code <br />LOCATION CODE <br />Cm, <br />REQUESTOR <br />CONTRACTOR / SERVICE REQUESTOR <br />CHECK if BILLING ADDRESS': <br />PHONE # <br />' /..) <br />FAX # <br />) <br />STATE Lt46, ZIP CA pi a z <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 <br />or activity will be billed to me or my business as identified on this form. <br />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 <br />COUNTY Ordinance Codes, Standards, STATE and FEDE AL laws. <br />/4,01 /4 <br />EXT. <br />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/s .te assessment <br />information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the <br />provided to me or my representative. <br />TYPE OF SERVICE REQUESTED: 61-21,1).7Z2J)-4;1& <br />COMMENTS: <br /> <br />A/01/ 0 <br />? 2023 SA N EN yk-,if, ON co HEA <br />Q <br /> , uN <br />'11 DEP4Y,TA 1_ 1 mEN <br />' ACCEPTED BY: I 1 ka jtrvi,,t_t_er_ EMPLOYEE #: V .9-- 2 73 DATE: Li/2.9- /2._ <br />ASSIGNED TO: (,,Zli )1 c 1 yvt, VC- EMPLOYEE #: i:9- _2 2 DATE: <br />Date Service CompletediOf already completed): SERVICE CODE: (- - ) k i , I E: <br /> i/,C, 2 Fee Amount: -. (,6 2_ Amount Paid /62,00 Payment Date <br />Payment Type <br />Vi 66t-- Invoice # Check # 17 / 6,4,-7/6.., Received By: <br />T-y <br />EHD 48-02-025 <br />REVISED 11/17/2003 SR FORM (Golden Rod)