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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property FACILITY ID # SERVICE REQUEST # <br />SRaDB-icbtA <br />OWNER! OPERATOR <br />CHECK if BILLING ADDRESS <br />IINC8CV,.)--0 04 rt--G -1-x- n 6-\ 0) <br />FACILITY NAME i <br />L0 3 r d ob s <br />SITE ADDRESS --- -?-)C.) <br />Street Number <br />S <br />Direction <br />Co l -,-corn;of <br />Street Name S i-C-Cid-Oiri City <br />DO <br />CtZip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />-4 i40\11/11 { a_ \ DI Street Number Street Name <br />CAY STATE ZIP _ <br />PHONE #1 EXT. <br />9(51) 3 qls - ng5-- <br />APN # LAND USE APPLICATION # <br />PHONE #2 EXT. <br />( ) <br />EMAIL BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />.C\CI 0 -e P\ r v-,--;.\---(-- cpnc)_ <br />CHECK if BILLING ADDRESS <br />BUSINESS NAME <br />1-- <br />1 , 1 <br />.e C) c'- irr;OC\ <br />PHONE # EXT. <br />HOME or MAILING ADDRESS <br />Pc\ PR ict 1 Dr <br />FAX # <br />( ) <br />CITY <br />> \ c C` \ (' 1 <br />STA • <br />TEC_ P <br />P - ZI <br />(j-S, <br />EMAIL 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: Y-4- <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 />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 pro me or my' <br />representative. Aii <br />- <br />TYPE OF SERVICE REQUESTED: N4 - \---- (CC1/4f nt-v1/4) consWic,01 <br /> <br />COMMENTS: <br />APR 0 a <br />4 2024 <br />SAN JOAQ <br />H ENV/RO (//41 COU °V.77.1 D ,A1,,AofevrA isi TY <br />"AR 7460 <br />ACCEPTED BY: br ,con.e m s EMPLOYEE #: DATE: LI r.t t 2_LA <br />ASSIGNED TO: EMPLOYEE #: DATE: 4 \ C l(.... <br />Date Service Completed (if already completed): SERVICE CODE: (2, L_, P/E: ke (dy <br />Fee Amount: 1,1 le 7 we Amount Pa" j :,w, o O Payment Date <br />Payment Type Type 0,Re_At-+ Invoice # Check #f7ef,..5-0.---6.-s Received By:a,7- <br />DATE: 919)08 <br />Title <br />EHD 48-02-025 SR FORM (Golden Rod) <br />03/22/23 <br />WaSLI 030