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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID # SERVICE REQUEST # <br /> FAQ21a3 SR ( 0 <3 �+ 5b 2 <br /> OWNER / OPERATOR <br /> Mqn a-ee , 'Sin 91, 1 c 0 r CHECK If BILLING ADDRESS ❑ <br /> FACILITY NAME <br /> NG1yiotK &42- Anr <br /> SITE ADDRESS lO �T 0 �7 S a r e \ ? Soh IRC 5 + t E S + U C k +- ori 5 a aStreet Number Direction Street Name Cit Zi Code <br /> HOME or MAILING ADDRESS ( If Different from Site Address ) <br /> :j o2 G0 1;2I 4:\ LAOOt Street Number Street Name <br /> CITY STATE ZIP <br /> < 4�0CK, 40Yl y4 gS212 <br /> PHONE # 1 ExT • APN # LAND USE APPLICATION # <br /> ( Fti1 ) & 444- 1 4? 4 -40( c$f <br /> PHONE #2 Ex-r . EMAIL BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR � /� Q �d ,eep S 1 n q t'1 ` do �- <br /> 1 _ 1 v CHECK If BILLING ADDRESS <br /> BUSINESS NAME I vaYl0ll� 9C42ct of PHONE # ExT , <br /> ( SL17 ) GLI L } 9 y ft 2; <br /> HOME or MAILING ADDRESS FAX # <br /> 3026 SO 41 <br /> CITY STATE ZIP EMAIL <br /> 4CADr <br /> C 1c � C Ira- 21 2 00 Q 10a Y+-t <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 /> 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 FEDERAL laws . <br /> �g- APPLICANT ' S SIGNATURE : DATE : 4Z 126 Z2023 <br /> PROPERTY I BUSINESS OWNER ❑ OPERATOR / & ANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required Title <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 pro dd to me or my <br /> representative . �•l/' <br /> TYPE OF SERVICE REQUESTED : InnoOwnp fskiCPI) � <br /> COMMENTS : r <br /> KQIJ /V <br /> J I COIN <br /> �ACTy 01 PAN NAC 1Y <br /> MFj� T <br /> ACCEPTED BY : 1w a h EMPLOYEE # : DATE : <br /> ASSIGNED TO : FOL <br /> ' ^ rVA EMPLOYEE # : DATE : _ - 23 <br /> Date Service Completed ( if alrea completed ) : SERVICE CODE : P / E : ( „ a <br /> Fee Amount : ` � a A �T <br /> mount Paid f (� � � Payment Date <br /> Payment Type Invoice # Check # + Z D (orlg Received By: <br /> EHD 48 -02 -025 SR FORM ( Golden Rod ) <br /> 03 /22 /23 <br />