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Site Address <br />Direction <br />Ext.APN # <br />BOS District Location Code <br />Requestor <br />Ext.Business Name Quiring General LLC >559 432-2600 <br />93727StateZipCityFresno <br />APPLICANT’S SIGNATURE: <br />Comments: <br />Accepted By<Employee#: <br />Employee#:Assigned to: <br />Service Code: <br />SR FORM (Golden Rod)EHD 48-02-025 <br />REVISED 11/17/2003 <br />Ext. <br />1 5T1 <br />Zip CodeStreet Number <br />Invoice # <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 <br />or activity 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 />Operator / Manager <br />Fee Amount: 4 <br />Payment Type <br />San Joaquin County Environmental Health Department <br />SERVICE REQUEST <br />FACILITY ID# <br />CONTRACTOR / SERVICE REQUESTOR <br />Jay Algaheim <br />Payment Date <br />/d./4^./5-% <br />Type of Business or Property <br />Owner <^peratq^ <br />SERVICE REQUEST# <br />Syomin <br />Check if Billing AddressD <br />Check if Billing Address <br />___________________________Clly <br />WMounSlYW <br />_________________________Street Name <br />Z'P%3>U(, <br />—May- <br />Phone#1 <br />QCflJ <br />Phone #2 <br />(XH) BBR-MAai <br />STATECft <br />Land Use Application # <br />Cind\^ ScWWotCi/ni Ex-ecuhu-t "Pifechj/ <br />FAciuTYNAME'j}M2-^rracec7 aj- <br />_____________________Street Name <br />Home or MAILING Address (If Different from Site Address) , q 30 <br />C^^treet Number <br />C|TY ^IpQYD_______ <br />>63 <br />St-51X7 <br />PATE: <5715 <br />DtTE:T? /■F/zZ <br />> ,.lp;E:/bO/ <br />Received By: <br />Date: 6-/1-2023 <br />Property / Business OwnerD Operator / Manager Other Authorized Agent <br />IfApplicant 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 <br />above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site-assessment <br />information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the sahi^iyefliftj^. <br />provided to me or my representative. <br />Type of Service Requested: <br />Date Service Competed (if already completed): <br />Amount Pai <br />Check# <br />1 <br />Home or Mailing Address 5118 e Clinton Way STE 201 <br />Phone # <br />J___ <br />Fax# <br />J___)_ <br />CA