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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property FACILITY ID # SERVICE REQUEST # <br />8 -1- LA- t-k 1- <br />OWNER / OPERATOR <br />41 -J <br />CHECK if BILLING ADDRESS ,-,, ,V0,/,k4fre-c-fv) :_.-- <br />FACIUTY NAMEAr "fA <br />in ecic: a n Cit. it <br />SITE ADDRESS <br />. 2 .1 3 87 Street Number <br />407 e .1"/ <br />Direction <br />(71 d (,,,- 7,64 I 6 /„-,d <br />Street Name <br />• ....) 77z- Kro 4 <br />City <br />?-..2 6 7 <br />Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />Street Number Street Name <br />Cry STATE ZIP <br />PHONE #1 Err. <br />(76° ) -fig -- 63o6. <br />APN # LAND USE APPLICATION # <br />PHONE #2 EXT. <br />( ) <br />EMAIL BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR 4 i 1 <br />ri-76fr-d ae,.d 4647,4-,./.„ _xi= CHECK if BILLING ADDRESS 12 <br />BUSINESS NAME A , <br />-41/77 e/ic. a /7 (7/1 - 1 <br />PHONE # <br />(7 6 0 ) fr7 - 6 306 <br />EXT. <br />HOME or MAILING ADDRESS <br />-:2 <br /> <br />i 3,1 Ci/GO1C1 L?, la 7 444 -4p 451- go 6( <br />FAX # <br />( ) <br />CITY jr- 06. A . sT A Z ip <br />-‘2 7 EMAIL i <br />r ie. A urv , h6eAdrisin /1?,/ eA, <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 this application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards, TATE and FEDERAL laws. <br /> <br />//- APPLICANT'S SIGNATURE: DATE: <br /> <br />PROPERTY / BUSINESS OWNER (2I 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 OF SERVICE REQUESTED: ryl() bd e_ '0c c elan I( e&/1 e_,GD <br />ii; 467444 7. <br />C Cei <br />COMMENTS: <br />Vz.,0 <br />NOV i 7 <br />f 2023 <br />84N Jodi Q <br />ii ENVIROILVIIN C ChilV EALrN o.iDAIE-A/r,,u. 7Y <br />AR rw ivr <br />ACCEPTED BY: -ex. k cm v"\ -e, VLIt • EMPLOYEE #: DATE: \-i \.20.23 <br />ASSIGNED TO: dcJ P. EMPLOYEE #: DATE: k 1 \ n \ -2,02.3 <br />Date Service Completed (if already completed): SERVICE CODE: 5 2_7) PIE: V0 (1)\ <br />Fee Amount: 4B . om Amount Paid 04% , . On Payment Date )1 /1 7 /2,3 <br />Payment Type cke jtd _ Invoice # Check # I-7211 (0-750 Received By: <br />Title <br />SR FORM (Golden Rod) EHD 48-02-025 <br />03/22/23