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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />5 CHOO Z- <br />FACILITY ID # SERVICE REQUEST # <br />SR0®37531 <br />OWNER! OPERATOR <br />6 J C tCHECK if BILLING ADDRESS 13 <br />FAciLrry NAME tna,Kma young- /qa-i-a' I- '1)00/ <br />SITE ADDRESS 0 7 <br />Street Number <br />tit) <br />Direction <br />gendAinin 117/1 a <br />Street Name <br />Si)Ce717A) <br />City Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) 70 0 .7-- <br />Street Number <br />-r os/ti 0 7aier D/2 <br />Street Name <br />CITY Sto Xiv A) STATE <br />ZIPC7 SP-0 tp <br />PHONE #1 EXT. <br />(A9) al7.--.7.3'/ <br />APN # LAND USE APPLICATION # <br />PHONE #2 EXT. <br />( ) <br />BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR 5 -r i L... am 0 o i? So re cci-2 10 CHECK if BILLING ADDRESS <br />BUSINESS NAME <br />1:::: , c -T—C- C) <br />PHONE # <br />( -'4 (/ ) a ci) - - ---2 3 <br />EXT. <br />HOME or MAILING ADDRESS FAx # <br />( ) <br />CITY STATE ZIP <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 <br />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 />APPLICANT'S SIGNATURE: <br /> <br />DATE: <br /> <br />PROPERTY! BUSINESS OWNER 12 OPERATOR / MANAGER D OTHER AUTHORIZED AGENT El <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 <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 ame time it is <br />provided to me or my representative. <br />TYPE OF SERVICE REQUESTED: CZn_gajf-Td7o1,--)• <br />• . - '`-k-EIVED <br />COMMENTS: DEC 1 4 2023 SAN JOA QUitV r' ,,ENViRoNm -OUNTy H; riALTH DER ENT4L A R Tm ENT <br />ACCEPTED BY: aLt6L EMPLOYEE #: cipt DATE: 49// t/A3 <br />ASSIGNED TO: AOCe-L EMPLOYEE #: C/F7 A)- DATE:A9A (L/423 <br />Date Service Completed' (if already completed): SERVICE CODE: 0 (.‘,2 / 13/E:/0 67_, <br />Fee Amount: / 2;-- <br />Amount Paid 25 /(e2 Payment Date <br />Payment Type C /heCK Invoice # Check # io,(4,Og 7/3 Received By: a7ir <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />094 VI DS <br />Title