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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID # F A 0 (1) 2 (e)(07i CV SERVICE REQUEST # 912.Q0 B-1- 9 k-k- q OWNER! OPERATOR CHECK if BILLING ADDRESS Lgorei (4/iC 2 eiti q -ye7)+0/4 FACILITY NAME Liti - I e 7-*olimS SITE ADDRESS Street Number Direction CaCIafenf - 0 Se btreet Name Liod, City 6W5rz5, Zip Code NONA or MAILING ADDRESS (If Different from Site Address) 3 -2 4t3 ..•,,__ _- • Street Number P4O)O1 Aq vc4 Street Name CITY STATE ZIP cm( aireA4v ("./-1 PHONE #1 EXT. (1,16)6 4? APN # LAND USE APPLICATION # PHONE #2 EXT. ( ) EMAIL BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR i—e010/ Qt2;:%4 /.1 lie') fe/ir U CHECK if BILLING ADDRESSO BUSINESS NAME , - I tun/A t'l 5 1.--/V PHONE # (10 ) 4t 7 2g c 2— EXT. HOME Or MAILING ADDRESS FAX # CITY STATE ZIP 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. 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 COUNTY Ordinance Codes, Standards, STATE and FEDERAL laws. APPLICANT'S SIGNATURE: DATE: II/ /// a l/ PROPERTY! BUSINESS OWNER 0 OPERATOR / MANAGER 0 OTHER AUTHORIZED AGENT 0 If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required GAUTHORIZATION 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 JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is provided to me Or Illy representative. TYPE OF SERVICE REQUESTED: difICA a OW\ er S t 10 PAYMENT COMMENTS: SAN HEALTH RECEIVED APR 1 8 2024 JOAQUIN COUNTY ENVIRONMENTAL DEPARTMENT DATE: 4 ‘‘e,keim ACCEPTED BY:?by t cuArve, NA . EMPLOYEE #: ASSIGNED TO: Fr CA-Irt CA S CO P—• EMPLOYEE #: DATE: Lo‘B‘2,44 Date Service Completed (if already completed): Fee Amount: ,1 SERVICE CODE: (11 P /7w 3 By: /1 ..1/' Amount 1 Paid 4 / 2,_ Payment Date Received Payment Typed e ..___ 77 Invoice # Check # EHD 48-02-025 SR FORM (Golden Rod) 03/22/23 ko9.11-01-tL4 Title