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�J[�i• vv.��i-l: vii a-'1l l 1�: • ■■\\l:•l ■l.l\■f'1L llLAL111 L1i1 t11�11�11.1\l r l SERVICE REQUEST Type of Business or Property FACILITY ID# SERVICE REQUEST# OWNER i OPERATOR ( , ( � CHECK If BILLING ADDRESSI FACILITY NAME vL 1 I� (©S�ITE.�V��4A4DDRESS C' V� tJ� Lti'IY�C�r� (2 (! �[�I�C. rYi � `'i S' 3 O Ki)liO%.i) Street Number Direction Street Name city my CO& NOME Or MAILING(ADDRESS (If Differe t from Site Address) `t 3 ` k 7 L/E Street Number 50yet Name C�tTY TATE ZIP PHONE#1#1 EXT APN# sI G 3 a 6 I s LAND USE APPLICATION# �'-1 a PHONE#2 EXT, BOS DISTRICT LOCATION CODE ( � ) 0'S_ / 3 CONTRACTOR / SERVICE REQUESTOR PAII REQUESTOR /] EN�' / D,n4rc r61 !lJ 1 I I<Z)W j� i CHECK if BILLING ADD94p� BUSINESS NAME !II PHONE# Exr. 'V ED IEC 2 2021 HOME Or MAILING ADDRESS�r LI� Cc,N�+��e� Ave (�# ) SAN JOA ENmmQUI COUNTY CITY SC4 1! �a5C J - STATE C A zip S/d ACTH DEP rOENT BILLING ACKNOWLEDGEMENT: 1, 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,STA and FEDERAL laws. APPLICANT'S SIGNATURE: (, G(.N& 01 DATE:_ PROPERTY/BUSINESS OWNER OPERATOR/MANACER ❑ OTHER At'riIORIZED AGENT❑ If APPLICANT is not the BILLING PARTY,proof of authorization to sign is required Title AUTHORIZATION 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 my representative. TYPE OF SERVICE REQUESTED: e rytlrilmurU SD.SP.� 12ck rom F 115}Itt �pc%G�I Ilhp ptbposc�well cur be nae . COMMENTS: Per -<epik per►n�'l SR n0 6�5U , sfPfli sys�PYv, co',�slslt �� 3- �O' inF; �tral�ar IlAe5- vied �,f Iwee+ lol:K* r•:c�: -to properly I6ACS. Dw,"erl} sl�fus of t'�lsllyt� ,;tell. rn - vQf'(y 3 fJAvC Co rt4-rer-aS s -7 " y4 (p(1, ACCEPTED BY: ! L Z EMPLOYEE#: DATE: /d Id/ I ASSIGNED TO: Q s EMPLOYEE#: DATE: IR121 2 / Date Service Completed (if already completed): SERVICE CODE: D PIE: g3oa Fee Amount: ) < Amount Pai Payment Date .�_ Payment Type i� Invoice# Check# /� 3 �S Received y: gJ