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DATE: <br />1. <br />Wz09-\6\0'43 <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Propetty FACILITY ID # SERVICE REQUEST # <br />(Z.(bla)B(v 5 4 <br />OWNER! OPERATOR <br />14 14 }-1 1-) 1 won/6 )-/A /176. CHECK if BILLING ADDRESS <br />FACILITY NAME • .1 J rj/i'L ti/n )e- 5 <br />r <br />—Klect- c c le <br />SITE ADDRESS /Q <br />Street Number Direction 0 0 V C2 tStreet Name <br />9 <br />City <br />4 2 0,2 <br />Zip Code <br />HOME Or MAILING ADDRESS (If Different from Site Address) 3-7--*- <br />Street Number 13 k yo 0 Fc(//5 ct r Street Name <br />CI CITY. <br />1 0 C K 10 91 <br />STATE <br />c 7-) <br />ZIP <br />Ci C A <br />PHONE #1 . Err. <br />( H4 aa ? 6'o ‘' <br />APN # LAND USE APPLICATION # <br />PHONE #2 Ext. <br />( ) <br />EMAIL BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR I A 1.1/-k i w..04/76, /_/(41/„7-6) <br />CHECK if BILLING ADDRESSIY <br />BUSINESS NAME 31 Th etyl i c 5 ..c...k. ied , ck , ckc ,kt* PHONE # <br />fr/s-) 3- Y c- K <br />Err. <br />6 <br />HOME or MAILING ADDRESS '9.- 13 KO (9 i< - (-----Gc 1/ 5 C t-‘ F AX ( ) <br />CITY 5-,1 c /._)-, .eh STATE cij ZIP Cz c a i , 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 applicati9n and that the work to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards, STATE EDERAL laws. <br />APPLICANT'S SIGNATURE: <br />PROPERTY / BUSINESS OWNER 0 OP ATOR / MANAGER 0 OTHER AUTHORIZED AGENT 0 <br />If APPLICANT IS not the BILLING PARTY, proof of authorization to sign is required Title <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 tAme or my <br />TYPE OF SERVICE REQUESTED: F-00 d c.c..);,-) us A-c,A-1. on f?.CP447144 , <br />COMMENTS: 6..... 2_3 2_'"..4 <br />f V 1 9 <br />Jr, 2023 60 AA, ir\ -,14,1c;)1,,,„ 'vitt fibA, cot, <br />N) u•-) 4f 11 p4'147-4(N4' 410-4,147, <br />ACCEPTED BY: "br i an r, e EMPLOYEE #: q eAr)G DATE: (1)(zA Ci \ i(b2,3 <br />ASSIGNED TO: cA 0 d i. os EMPLOYEE #: ci ey2s:s DATE: QAP I t ct I ze,-13 <br />Date Service Completed (if already completed): SERVICE CODE: (1)(o k P I E: kcfaz <br />Fee Amount: S ( . (Da) Amount Paid SZ12.--- <br />Payment Date (i)//,712 3 <br />Payment Type 6oui d Invoice # <br />-"Cjc3eZ-# : /(p/-1021126/ Received By: <br />representative. <br />EHD 48-02-025 <br /> SR FORM (Golden Rod) <br />03/22/23