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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property FACILITY ID # <br />E—Aaili(i- \ -i cce- C, <br />SERVICE REQUEST # <br />SROCDB-1- (QS t-V <br />OWNER/OPERATOR BnINS Z.,./ 6)()OC 1 f‘j C CHECK if BILLING ADDRESS <br />FACILITY NAME f NIO N 7- Cell/ re g- Ll6M) i2 0•- P4 0 t6 <br />SITE ADDRESS--) .:..;0 <br />Street Number <br />C <br />Direction <br />E)ze r-4a Arr 1- <br />Street Name <br />3-"roc_ K r 0 lx" <br />City <br />67506 <br />Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />Street Number <br />1,0 n.,06- L?6Ck Cu K1`7 / <br />Street Name <br />CITY' C, C (*, 7 ' / k- 2 STATE ZIP <br /> <br />PHONE #1 EXT. <br />(20 )411.3--0014-1- <br />APN # LAND USE APPLICATION # <br />PHONE #2 EXT. <br />( ) <br />EMAIL BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR n,,, tSri/ IV 5 j_. i 000 .023 / pc CHECK if BILLING ADDRESS <br />BUSINESS NAME F. rE _{0 ,„--r- 6: eN-7-612 2._ I 0 u o iz. 6 1-7 2/c &-- PHONE # <br />( - 023 007 11- <br />ExT. <br />HOME or MAILING ADDRESS 0-7/ FAX # <br />( ) <br />CITY STATE c A- ZIP '75 2 0 1 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, Standards, STATE and FEDERAL laws. <br /> <br />DATE: 0 (1 2S (2 <br /> <br />APPLICANT'S SIGNATURE: <br /> <br />PROPERTY! BUSINESS OWNER 0 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: cATI(Lirici. oc Ow n6 s VNA p Pec ITINT Eivzo <br />COMMENTS: 14N 2 5 2024 sAN jai , <br />HE,E14^rv,.L ,IRO,;,81tcou,„7I, <br />''''-dIRNENT <br />ACCEPTED BY: by kw(' \(\: i\A . EMPLOYEE #: DATE:D zs ‘2_4 <br />ASSIGNED TO: C \ Cad 1 0,_ 11/4_, \ EMPLOYEE #: DATE: QA 7,...512A <br />Date Service Completed (if already completed): SERVICE CODE: P/E: \(002„ <br />Fee Amount: $ \ (62_ Amount Paid i Lora . --- Payment Date ( (2-S-12_<4 . <br />Payment Type raft d Invoice # -Checzokillizif : 1-1--IT1 A on, I Received By: a4.57-?1 <br />Title <br />END 48-02-025 <br />03/22/23 <br />SR FORM (Golden Rod) <br />-P(Aolgoo