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APPLICANT'S SIGNATUR <br />PROPERTY! BUSINESS OWNER. <br />DATE: O -2 <br />OPERATOR / MANAGER 0 OTHER AUTHORIZED AGENT 0 <br />If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required Title <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />14A, <br />FACILITY ID # <br />(-e <br />SERVICE REQUEST # <br />OWNER / OPERATOR ( i CHECK if BILLING ADDRESS <br />----1 CriCI tu e_ ge Ye3 -- r <br />FACILITY NAME 1-005 kef Ye5 - -0c•\ --\-- <br />Street Number Direction <br />SITE ADDRESS ADDRESS <br />Street Name <br />5P c k 465/1 <br />City <br />675 266 <br />Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />6 6 41 (P_ (Jell (L/ Street Number Cck Street Name <br />CITY STATE ZIP <br />-3 -0C1(1-0 n q_5,20K <br />PHONE #1 Err. <br />UM ) q10 <br />APN # LAND USE APPLICATION # <br />PHONE #2 EXT. <br />aq)351-tqc)1 <br />EMAIL/2 i <br />(tic?' r i'o.---3 z-i26.,(a,t(Iroc:1,(_‘-et.,_ <br />BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR CHECK if BILLING ADDRESS <br />BUSINESS NAME PHONE # <br />( ) <br />Err. <br />HOME or MAILING ADDRESS FAX # <br />( ) <br />CITY STATE ZIP EMAIL <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, Standard TATE and FEDERAL laws. <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: R._(=\9. pAy,,,,E.A... <br />-614. rUCA/1 <br />COMMENTS: (2....932._ <br />. -, "' t <br />164 Vete <br />DEC 04 2023 <br /> <br />skvJoA„ ei p,„„ .wijov , <br />liek7„Rolviteouiv r y <br />' r 7 DEpA 47 triA L <br />ACCEPTED BY: \iN 2..e.....riC EMPLOYEE #: 62J3 DATE: 4,4/-21T <br />ASSIGNED TO: 'S----0 LA-1.,/1 /4-12t_ek.At i EMPLOYEE #: £.45' g' cl DATE: ( 211f: 1.2_7 -) <br />Date Service Completed (if already completed): SERVICE CODE: g2....?_) PIE! 160 / <br />Fee Amount: Amount Paid 5L+sc„, Payment Date 1 21 <br />Payment Type caAAA., Invoice # Check # Received By: C-4570-' <br />END 48-02-025 <br /> SR FORM (Golden Rod),,-- <br />03/22/23