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DATE: Viy ..2 2o2/
<br />OTHER AUTHORIZED AGENT 0 PROPERTY! BUSINESS OWNER 0 OPERATOR! MANAGER 0
<br />*friAzate APPLICANT'S SIGNATURE:
<br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT
<br />SERVICE REQUEST
<br />Type of Business or Property FACILITY ID #
<br />RAVD 2-54-.\
<br />SERVICE REQUEST #
<br />ea)8812_
<br />OWNER / OPERATOR.-
<br />CHECK if BILLING ADDRESS El ot,
<br />,,, .,..z.c___, r4
<br />FACILITY NAME '- aw,e5 4/24,,,, w ehet,gok,,, .--7---
<br />SITE ADDRESS I/ 00 Street Number Direction ekki fid5 tree(Name
<br />50blivieik-, 0
<br />City
<br />/3"-S//
<br />Zip Code
<br />HOME or MAILING ADDRESS (If Different from Site Address)
<br />3754 57--eNe C.04/4- S---t . Street Number Street Name
<br />CITY4 STATE ZIP et nkfrieye- 9:5W3
<br />PHONE #1 EXT.
<br />(Cap ) 237- ?LT)
<br />APN # LAND USE APPLICATION #
<br />PHONE #2 EXT.
<br />OP ) .5761— 37 /17
<br />EMAIL d
<br />eiwikehilia .irikd. ee707
<br />BOS DISTRICT LOCATION CODE
<br />CONTRACTOR / SZRVICE REQUESTOR
<br />REQUESTOR
<br />CHECK if BILLING ADDRESS
<br />BUSINESS NAME j
<br />414die5 16711Z-k8/ ,,,ek ig,„,4„,-7:- PHONE # ,,),,,,i_.3,.,_57
<br />FAX #
<br />( )
<br />EXT.
<br />HOME or IpING ADDRESS , .37 $72)nc-
<br />, i_
<br />9.5113
<br />CITYArt.../ iv s(_-rff
<br />zi p 67,51rir EmAi..44,,41,4s,.44A,-,,.,..,„,,,i
<br />BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authori d 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 FEDER L laws.
<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 to me or my
<br />representative.
<br />TYPE OF SERVICE REQUESTED: gein c‘1, \ cd-roca, OAF F) PAYMENT
<br />COMMENTS: RECEIVED
<br />MAY 0 2 2024
<br />SAN JOAQUIN COUNTY
<br />ENVIRONMENTAL
<br />HEALTH DEPARTMENT
<br />ACCEPTED BY: bk,--'keLnr) t p EMPLOYEE #: DATE: 05 icD2.1-2.4
<br />ASSIGNED TO: IL-ran c....k scx, R . EMPLOYEE #: DATE: 05 \ 02.12.4-1
<br />Date Service Completed (if already completed): SERVICE CODE: CL G. \ /E: (0 12)3
<br />Fee Amount: km4 -2_ C6 12) Amount Paid Z, 2 Payment Dat
<br />Payment Type V/ Invoice # 91troic #/ De.??-<-/ Received By:
<br />SR FORM (Golden Rod) EHD 48-02-025
<br />03/22/23
<br />7(ZO5i--11-\1-1-M
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