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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT px)052/ gepite, <br />SERVICE REQUEST <br />Type of Business or Property <br />r-- D <br />(AM &'(_,B-45(03 <br />FACILITY ID # SERVICE REQUEST # <br />OWNER / OPERATOR <br />CHECK if BILLING ADDRESS SOA- iii5A .1- .5/x/6_ if A U Lit- il <br />FACILITY NAME <br />MAT -ri <br />SITE ADDRESS CI <br />i 1 ‘ et <br />Street Number <br />otiii, <br />Direction <br />3 --.551-7-/ 6 ic A v E <br />Street Name <br />/4/4 Nre—C,4- City cr-C33 F Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />Street Name Street Number <br />Ow STATE ZIP <br />PHONE #1 ExT. APN # LAND USE APPLICATION # <br />PHONE #2 ExT. <br />( ) <br />EMAIL <br />AuLAKI-13Az1 i.,_,. <br />BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR (-7 CHECK if BILLING ADDRESS <br />BUsiNEss NAME PHONE # <br />( ) <br />EXT . <br />HOME or MAILING ADDRESS FAX # <br />( ) <br />Crrv 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, Standards, ST TE and FEDER laws. <br />APPLICANT'S SIGNATURE: <br />PROPERTY! BUSINESS OWNER 0 OPERATe / 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: C6-Yt- -' Gck *--eL.A. <br />. •-• I mi—il I <br />.,/k p,12 RECFJVED <br />COMMENTS: <br /> <br />' DEC 26 2023 <br /> <br />/ c • ,. . / / SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />) . , ACCEPTED BY: EMPLOYEE #: t? 6 e DATE: 1 2 /2 6/2 _ 3 • <br /> ASSIGNED TO : 0 EMPLOYEE #: 71- --g S DATE: / 2 /2 64 /2 r, <br />Date Service Complete (if already completed): <br />A <br />SERVICE CODE: o 6 / I E: e ogi <br />Fee Amount: 5 / 6 2 _ Amount Paid # /4 Payment Date 1 ,...1, "1...0 <br />Payment Type VISA_ Invoice # 9ed1# [1-- / c/ 1 -?-- e- Received <br />DATE: 1212f -2 /. <br />EHD 48-02-025 <br /> SR FORM (Golden Rod) <br />03/22/23