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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property FACILITY ID # SERVICE REQUEST # <br />OWNER! OPERAT05, <br />CHECK if <br />May it,. K OPnlaleZ_ <br />BILLING ADDRESS <br />FACIUTY NAME <br />fri <br />A i . 1 , p <br /> <br />etrik• 5 (A p is•-t 5 c r i a. <br />sjTE ADDRESS <br />IC, ao I Street Number Direction 5 q CA r I eialieet Naad L-6 1-Itcpy 41 io,e4° <br />HOME or MAIUNG ADDRESS (If Different from Site Address) <br />1 41 ,11 Kerry Cet tlrt Street Number Street Name <br /> <br />CITY 1,,ct i 1 - <br />+t r? <br />STATE <br /> <br />li ( /1"" <br />ZIP J <br />ct 5 330 <br />PHONE #1 EXT. <br />(4615) 11 (0 0 % q 6 8' <br />APN # LAND USE APPLICATION # <br />PHONE #2 EXT. <br />( ) <br />BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />MC, C bY)c essi b n "Tak.i)t IrS /All6 oil 14011 1'1'4'1 CHECK if BILLING ADDRESS <br />BUSINESS NAME a A 1 r) nt Ho- 5 rtipuseriA, <br />PHONE # EXT. <br />(201) 5qq —°2-5 S <br />HOME or MAILING ADDRESS <br />X1 <br />A _. ts <br />1 E MIOPr tf-S\Ne._ W2- <br />FAX # <br />( ) <br />CITY S\--DcAL-Vus-1 <br />STATE CI k ZIP 9 5205 <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 <br />or activity 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 />APPLICANTS SIGNATURE: <br />PROPERTY/ BUSINESS OWNE OPERATOR / MANAGER 0 OTHER AUTHORIZED AGENT 0 <br />COUNTY Ordinance Codes, Standards, ST ATE and FEDERAL laws. <br />DATE: 03/ 11 2 -ovt I- <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 <br />above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment <br />information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br />provided to me or my representative. PAVIIIii&A <br />TYPE OF OF SERVICE REQUESTED: t1/4.A.F- F 9 (cur.. 'Pe.vi <br />1 <br />rteCEivED <br />COMMENTS: <br />jr:::- i •wirs: <br />MAR ii 2024 SAN U N C E NVIROIVAI U NTY <br />HEALTH DEpApENTAL __Tiwevr <br />ACCEPTED BY: "&ri an e,e_ u EMPLOYEE #: DATE: 3\ lk V2.1.4 <br />ASSIGNED TO: kiecuAlt,e EMPLOYEE #: DATE: "SI 1% \ 2)..4 <br />Date Service Completed (if already completed): SERVICE CODE: 52.: PIE:‘tom <br />Fee Amount: LIU ;1 Amount Paid IF46(p — -------- (4. <br />Payment Date ‘1,t tati. <br />Payment Type ratqa Invoice # r'lltle,eNft-- tiiitIts Received By: tAkp . <br />END 48-02-025 <br /> SR FORM (Golden Rod) <br />REVISED 11/17/2003