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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property FACILITY ID # <br />71- /- r r 2 2 2 ro <br />SERVICE REQUEST # <br />SQ.Mitiri5 <br />OWNER/OPERATOR <br />a) ilf .\ f\Anyv,v1i--) CHECK if BILLING ADDRESS — <br />FACILITY NAME MI( . -A 1.N1W_,i il •A)Cd TVA/0,C- <br />SITE ADDRESS li) 1-0 <br />Street Number <br />S <br />Direction <br />S 0 OW" ocbotico <br />Street Name <br />v_ockt <br />City <br />ols-zko <br />Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) t 0L0 <br />Street Number <br />S .14-vk c4 <br />Street Name <br />CITY <br />1.7 <br />STATE CA ZIP <br />PHONE #1 Exr. <br />( 201) g s --A O io cl <br />APN # LAND USE APPLICATION # <br />PHONE #2 Exr. <br />( ) <br />EMAIL BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR Saa 10 <br />(V\-1)\(\ \A- -D CHECK if BILLING ADDRESS <br />BUSINESS NAME A i 63,10,0 -R,0 6 ..rpe,,t,,i(_ g15- I DL0'1' <br />HomE or MAILING ADDRESS FAX # <br />( ) <br />CITY ? 6 \ \k9/10.50.,--\ STATE CA_ ZIP q S 34 7. 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 />/4/71% <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 />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 provided to me Or my <br />representative. <br />TYPE OF SERVICE REQUESTED: ?,..Ax,k -te,v\AcA4 covoo.A.L1-4v0--\z, , Re- 111EN 1 <br />CEI COMMENTS: ITT1 ... FEE? n , <br />. 4 2024 <br />8441 JOAQ <br />,7A1 COW/rY ti Efillql?0/1Al Ekrki c„.Etv rAt „ <br />-kiaritizAi r <br />ACCEPTED BYO/"V\- EMPLOYEE #: DATE:1\ .7 I 7›. I <br />ASSIGNED TO: IV•y2 EMPLOYEE #: DATE: <br />Date Service Completed (if already completed): SERVICE CODE: 0 Li) \ PIE:1 U0.3 <br />Fee Amounfti t U2._ Amount Pai 62,2 ,6yD Payment Date <br />Payment Type (i),,zok -- Invoice # Check # Received By: di - <br />EFID 48-02-025 <br />03/22/23 <br />SR FORM (Golden Rod) , <br />Pg °SUR—B—D • <br />APPLICANT'S SIGNATURE: DATE: