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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />60,v <br />FACILITY ID # <br />t-FATIABc‘cik <br />SERVICE REQUEST # <br />SPED(1)n a 2- <br />OWNER / OPERATOR <br />CHECK if BILLING A DDRESS <br />?1--A- C- e .1-f\-) C-- e_\,ex / t___ 6E-4 S I <br />FACILITY NAME <br />r-r\ n . /A.) P LA c 6. <br />SITE ADDRESS <br />17 2-7 I Street Number Direction 0 6 12-0 6 ci-gteetieki" V I cro 4 City <br />C15253 <br />Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />P 0 i',c, $ 3 4,4 Street Number Street Name <br />CITY STATE ZIP <br />ki 1 GTO e- C A 526-3 <br />PHONE #1 Err. <br />0°CP 32- 9 S-500 <br />APN # LAND USE APPLICATION # <br />PHONE #2 EXT. <br />(915''11 32A 57)St, <br />EMAIL <br />KNOWN-It-006Z(cryytcas1 • kie t- <br />BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />C \./ u0 s t ii.C^ ee-ig s 1 CHECK if BILLING Et ADDRESS <br />BUSINESS NAME . <br />,Ltkje) P CA' C. E / n) C.__ <br />PHoNE# Err. <br />061 32g 53-00 <br />HOME or MAILING ADDRESS <br />Pe) 60x 34/4/ <br />FAx# <br />( ) <br />ry (1 I ( reA2 STATE,e_ ZIP EMAILC rirtijoo/cA. c .e 63 in,,,ca J.7, /.5,,..-046._ 3 <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: DATE: <br />PROPERTY / BUSINESS OWNERkr OPERATOR / MANAGER 0 OTHER AUTHORIZED AGENT 0 <br />If APPLICANT Is not the BILLING PARTY, proof of authorization to sign is required <br />7/g//9 3 <br /> <br />Title <br /> <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 or my <br />representative. <br />TYPE OF SERVICE REQUESTED: 2-- H P___ c- t c- ci / v c ke-- <br />Al;:iritt.iii <br />COMMENTS: <br />Ce-nio,„ <br />41NAD ?Oa <br />"eV. fibON COU <br />4f DiCnekOilr l'irY ../141p.,.214 <br />- "Mekr <br />ACCEPTED BY: <br />C--4.;t (4"-q e'-c_ C-, <br />EMPLOYEE #: DATE: '-)___ ; ( _ 2. 3 <br />ASSIGNED TO: )i c_ (ie.{ -2 EMPLOYEE #: DATE: <br />Date Service Completed (if already completed): SERVICE CODE: .,t---.2.. .:". P/E: a2oi <br />Fee Amount: A)..2.(4 cp(k Amount Paid <br />—!--1.• - Payment Date fI 31 -2 .3 <br />Payment Type Invoice # Check # 1 1-i s e Received By: atitr <br />OraQ).6- (-01 CC.1L1tP6 <br />SR FORM (Golden Rod) <br />Feik‹,abN)-31,1 <br />END 48-02-025 <br />03/22/23