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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID # A ON 2 .33B SERVICE REQUEST # sizzo (-6 -1- co 2c OWNER/OPERATOR i\A . i dYY oVk)r% - M c,t,v -I- b,) e-1., CHECK if BILLING ADDRESS FAciurr NAME t 1 1--tct iv ,S B7 Z ok Ca-ic-e,7 SITE ADDRESS 6 1 c;\ Street Number -.... Direction 0, a/ 4-€ k lni a Street Name 5-\-,06-le4,7}" City a\c; 206 Zip Code HOME Or MAILING ADDRESS (If Different from Site Address) I 2 k Street Number '214 -Street Name CITY STATE ZIP 0152,0-6 PHONE #1 Ex-r. APN # LAND USE APPLICATION # PHONE #2 EXT. ( ) EMAIL BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR .,„ rUkaf V 030 l'-, ,(.2e-5 .,--,0 — 1/14 Gt V--1- f.) e-7_, CHECK if BILLING ADDRESS BUSINESS NAME ) 9 / 7 Lc. Co -,Le - PHONE # ( LP-A) Z144 ExT. HOME or MAILING ADDRESS C kot v -I --e v ( A ) et FAX # ( ) CITY c.,..1.,„,6)6.4.n...., STATE c A ZIP ov--)- L. a 6., EMAIL BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as identified on this form. 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 COUNTY Ordinance Codes, Standards, STATE and FEDERAL laws. DATE: VI 7-Z1 APPLICANT'S SIGNATURE: PROPERTY! BUSINESS OWNEI,.. OPERATOR! MANAGER 0 OTHER AUTHORIZED AGENT 0 If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required 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/site assessment information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. TYPE OF SERVICE REQUESTED: C,hCLVli3e, oc OW nel skr\:i p Iiio "67 N7- oleo) COMMENTS: 17 JoiN 2024 Jo H444/7.8040QA/IiititPOuiv 4, 1)EPAiii,7. rk Wiv t , ACCEPTED BY: "V)60..nne i.....A , EMPLOYEE #: DATE: cot t n. \ 2cf ASSIGNED TO: CI, k ckkx.ck; a M , EMPLOYEE #: DATE: 01 Or V2.24 Date Service Completed (if already completed): SERVICE CODE: 06. i P I E: Fee Amount: S,(2.. 00 Amount Pai /6,2, Do Payment Date Payment Type Type a 4_,_:_71_ Invoice # Check # Received By: 6— END 48-02-025 SR FORM (Golden Rod) 03/22/23 V2(2°1011 14‘40 5 Title