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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property FACILITY ID It SERVICE REQUEST It <br />5 R ca 8 7 4 7 7 <br />OWNER / OPERATOR , ) -f-ta.r'r t E9 . Oa cLon CHECK if BILLING ADDRESS el <br />FACILITY NAME 677 me illy7) u g.,..e rec. 7,.._ . Iktit 0,1 ,, /7?e4,/,__ <br />SITE ADDRESS Li qs- ( <br />1 Street Number Direction <br />pa -6 6.7 e Street Name ,$)-w>/opy City <br />coe,- <br />Zip Code <br />HOME or MAILING ADDRFRS (If Ilifferent from Site Address) / 0 <br />Street Number <br />CeA' e b rzyti on way <br />Street Name <br />CITY ST ()e( 0).1--/---e-6 CA <br />PHONE #1 EXT. <br />— ( 7 '7') 2 /7- <br />APN # LAND USE APPLICATION # <br />PHONE #2 EXT. PHONE <br />( ) <br />EMAIL A <br />c.--r- in-Paz{z, ('Pse qin4u", <br />BOS DISTRICT <br />ci.,y)_ <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />/ , / , CHECK if BILLING ADDRESS <br />BUSINESS NAME PHONE # <br />( ) <br />EXT. <br />HOME or MAILING ADDRESS Fax# <br />( ) <br />CITY 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, STATE and FEDERAL laws. <br />APPLICANT'S SIGNATURE: <br /> <br />DATE: <br /> <br />PROPERTY / BUSINESS OWNER 0 OPERATOR / MANAGER 0 OTHER AUTHORIZED AGENT 0 <br /> <br />If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required 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. PAtr. <br />TYPE OF SERVICE REQUESTED: , / ' / t / / / / <br />I rs -7 R c VI" cts/- ii,,i) <br />COMMENTS: <br />n <br />SA N JOA <br />u 2023 <br />1-i lv vIR'QuIN c 4071 on,44 . ouNr _ <br />rT 771/7-Air <br />ACCEPTED BY: a/Le.C_/ EMPLOYEE It: (.1 ki (S' DATE: <br />ASSIGNED TO: <br />44 (tCek EMPLOYEE It: c7f ,.-., DATE: ii</.30/23 <br />Date Service Completed (if already completed): 1 SERVICE CODE: r) 6,:, / PIE: / 67 03 <br />Fee Amount: Amount Paid V--) Payment Date # 2.:2 <br />I Received Payment Typ€ Invoice # Check # 3 7 gs 7 y: cp-- <br />P3 Z54 <br />END 48-02-025 <br /> SR FORM (Golden Rod) <br />03/22/23 <br />PRo9-1