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Title <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property FACILITY ID # <br />l'Por 01/4)D- I U2 i q <br />SERVICE REQUEST # <br />C1Z Ol>140(2L I <br />OWNER! OPERATOR C- yol„W‘ct a CHECK if BILLING ADDRESS ,cata_s- <br />FACIUTY NAME <br />\ Kv9-wa 6c,ttac ft!,,,,RRES,/ <br />. i Ne Street Number Direction 1 0C\ \AI kkeli lila m 0 yi L_N( <br />' L C cV 1 Q 32_'-.1 0 i Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) 1 000 <br />Street Number \A) 1<e_illovvv4,4-1, <br />Street (jr. ame <br />CITY P LOOl k <br />STATE ZI <br />CA-'62 LI L) <br />PHONE #1 EXT. APN # LAND USE APPLICATION # <br />PHONE #2 Exr. <br />( ) <br />EMAIL BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE RE UESTOR <br />REQUESTOR Farh?lb ct 1.S4[aSS' <br />CHECK if BILLING ADDRESS <br />BUSINESS NAME <br />—TO 4 (12eA l C t jcet JCILS C <br />PHONE # _ __(:)0_ _ ..... (XX .2 2.1-qt <br />.E T. <br />HOME or MAILING ADDRESS Fax# <br />I 00C/ VV W4-160/ an (f\ A-Pti" ) <br />CITY <br />( <br />STATE <br />- <br /> ZIP6 CO-7_4HD 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: C(i, CCi..("S Ck\ DATE: <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 provided to me Of my <br />representative. <br />TYPE OF SERVICE REQUESTED: ifiii ifilf /ti <br />COMMENTS: V1 D n 4 <br />--* f Att\e\ <br />ek-ii, r <br />, 'FlotototAr-6 4/1? . , o <br />' '• ;0 evAck. 6:4141./Oxi <br />e 0 <br />6,44'116,QuAt c 0 <br />2 24 <br />47-6, ontft ou4,„. <br />C'p, AsIrA I , r <br />—kyr <br />ACCEPTED BY: NIA, EMPLOYEE #: DATE: i.4 I ZS I 2.1 <br />ASSIGNED TO: .11L EMPLOYEE #: DATE: <br />Date Service Completed (if already completed): <br />Fee Amount: <br /> S CODE: SERVICE (..xe PIE: 03 1 <br />Amount Pal /,, ,n Payment Date 972S7 <br /> 4 <br />Payment Type Invoice # Check # Receiv d By: WO <br />EHD 48-02-025 <br />SR FORM (Golden Rod) <br />03/22/23