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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property -ic •••• FACILITY ID OD --i- # 1-1-- SERVICE REQUEST # aP (3 -1 -7 )3 OWNER! OPERATOR CHECK if BILLING ADDRESS afl 1_1 0 ik i \ kp A FACILITY NAME , N A ,- 1 , V f • Vp 't, pA p--L. -rt Ll'iPq 1-1-0--A 3 SITE ADDRESS Street Number <- I Direction 5 f), co,ktv"-A 54. Street Name Lo ...‘, City c\ v-i 0 Zip Code HOME Or MAILING ADDRESS (If Different from Site Address) \ 50 tD Street Number k—k u 4- OA', A5 ,7 ek . S 0 3 Street Name CITY I STATE( ZIP L 0 1 \ Ltp, q s 7_ ti PHONE #1 EXT. (Z() ) Q10 2 • ilH 9 -' APN # LAND USE APPLICATION # PHONE #2 ExT. (?..1) l'i Da S 03 EMAIL BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR c5 CWA-g., CHECK if BILLING ADDRESS BUSINESS NAME PHONE # EXT. ( ) HOME or MAILING ADDRESS FAX # ( ) CITY STATE ZIP 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. APPLICANT'S SIGNATURE: PROPERTY! BUSINESS OWNER 0 " 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 provickpAwe or my representative. TYPE OF SERVICE REQUESTED: lit Cifte..."'"fir I' 11/1) COMMENTS: DkatiV, of worship rk-ii 1 5 2024 844/.10,4 EA/14 QUbv ,,,r7A feivr ACCEPTED BY: L 0 Irai EMPLOYEE #: DATE: 2.... 15.1 .4.1 ASSIGNED TO: C EMPLOYEE #: DATE: 2_, I 5 O.,/ etaa 0 Date Service Completed (if already completed): SERVICE CODE: Dce, i PIE: 1 0 3 Fee Amount: tit 1( a '00 Amount Pai IL 2 , 00 Payment Date /-2-• _ N't i Payment Type i 40 i Invoice # Check # Receive By: END 48-02-025 03/22/23 SR FORM (Golden Rod) poos(-1-7(to'sz DATE: Title