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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property FACILITY ID # SERVICE REQUEST # <br />S cZ),Z) Bi- 5 q Co <br />OWNER / OPERATOR <br />CHECK if BILLING ADDRESS <br />?eft th El\I D' So t\I , <br />FACILITY NAME <br />SITE ADDRESS <br />Street Number Direction Street Name City Zip Code <br />HOME Or MAILING ADDRESS (If Different from Site Address) <br />a(0 1-11 COC )1IC116 ti ' Street Number Street Name <br />CITY STATE ZIP MO (14eCa, CO' <br /> <br />PHONE #1 #1 Err. <br />(1,5r; ) 30'4 ‘i 9-03 <br />APN # LAND USE APPLICATION # <br />PHONE #2 Ex-r. <br />( ) <br />EMAIL BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />rgt---Ki U, 5 0 ht r-01- ) k: ' CHECK if BILLING ADDRESS LI <br />BUSINESS NAME PHONE # EXT. <br />HOME or MAILING ADDRESS <br />Q-(49 q c1 C0011.6t9e, 19 I. <br />Fax # <br />( ) <br />CITY Me <br />ccz, STATE,- <br />( Ol <br />ZIP of 5 3 59,_ 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 a the work to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards, STATE and D RA laws. <br />APPLICANT'S SIGNATURE: DATE: <br /> <br />I 9 -10 2 3 <br />PROPERTY / BUSINESS OWNER 0 OPERAT / MANAGER OTHER AUTHORIZED AGENT 0 <br />If APPLICANT is not the BILLINC PARTY pro o rization 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 Agcoyided to me or my <br />representative. FRYMEN <br />TYPE OF SERVICE REQUESTED: M c; plan (2.eu i eu-) nECEIVED <br />COMMENTS: DEC 19 2023 <br />11._ ,JOAQuw cowny wimmumemirm. 4iNamiloaRinmeor <br />ACCEPTED BY: by- i MAW M , EMPLOYEE #: DATE: <br />ASSIGNED TO: \A.tI F. EMPLOYEE #: DATE:121tCi (2:3 <br />Date Service Completed (if already completed): SERVICE CODE: 523 P / E: \ IA \ <br />Fee Amount: 131-3/4-B(0 . M Amount Paid <br />--- Likiiv4( 0 <br />Payment Date [21(61(2 <br />Received By: wald Payment Type C\aAd Invoice # pbeeicir .. 1---701.4.12--isi <br />EHD 48-02-025 <br />03/22/23 <br />SR FORM (Golden Rod) <br />FP 091 <br />Title