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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID# SERVICE REQUEST# OWNER I OPERATOR r) p f C !' J e?V s • �!/t ��t + (� �� r V CHECK If BILLING ADDRESS FACILITY NAME -7�,LQ S L) C O+e p i�i SITE ADDRESS Z Y YC� S i t {r S� ��r Stack }! 52a Street Number Diraction Street Name ci ZI Code HOME or�MAILING ADDRESS (if Different from Site Address) 2- J/ Rt V rCaV e r Street Number Street Nam CITY OJ 1 VCr �J]_ f`,,4 ,J STATE r J� z1P f53fa 7 PHONE#1 Exr. APN# LAND USE JAPPLICATION# qcq) '!sro - �05 6 PHONE#2 EXT, EMAIL BOS DISTRICT LOCATION CDDE ) CONTRACTOR 1 SERVICE REQUESTOR REQUESTOR F Jy ! ([ r l f-v'o s o I CHECK If BILLING ADDRESS BUSINESS NAME I�(GS l �/� I PHONE# EXT. HOME or MAILING ADD ESS FAX# ZNII i ut'( C d ve Dar ( ? CITY /p !v � i , /� STATE / ZIP / -J 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. also certify that I have prepared this application and that work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, Standards, ST� and FEDERAL p APPLICANT'S SIGNATURE: s�-�^� DATE- PROPERTY/BUSINESS OWNER❑; OPERATOR A{ R ❑ OTHER AUTHORIZED AGENT ❑ If APPLICANTIfS not the BILLING P Pdof of authorization to sign is required Title 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 JOAOUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It is available and at the same time it Is provided to me or my representative. 1� TYPE OF SERVICE REQUESTED: CXDY -St-JA C.,iho h nECEIVEri COMMENTS: ANR o 9 2024 SAN JOAQUIN Cou EN HEALTH NMEN-rAC DEPARTMENT ACCEPTED BY:�Y tUn�� EMPLOYEE#: DATE: 4{C�1•2-4 ASSIGNEE)TO: IF EMPLOYEE#: DATE: G I'Zy Date Service Completed (if already completed): SERVICE CODE: @(o I P I (C 3 Fee Amount: Amount Amount Paid oZ Payment Date Gt Payment Type V 1(r - Invoice # Ch # � Received By: EHD 48-02-025 SR FORM(Golden Rod) O3f22/23 0�q�� -15