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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST P 2 D I (o 0 q3!9 Type of Business or Property FACILITY ID# ERVICE REQUEST# FA000283 S 00SLN- -.S OWNER/OPERATOR CHECK If BILLING ADDRESS FACILITY NAME r- ,G i'YA r ke�- l 1 '� SITE ADDRESS vl.lvs/ v..J C� 6 to CO`n S T 5*61--t Street Number Olreetion Street Name city Zin Code N E orMAILING ADDREm ite Address) Cr � LDff^ f I � Street Number Street Name C17Y _] Q h4cOYA STATE ZIP �G J PHONE#1 / / ^ I Ems' APN# LAND USE APPLICATION# G PHONE#2 ExT BOS DISTRICT LOCATION CODE CONTRACTOR/ SERVICE REQUESTOR REQUESTOf� - `^ e � `V Z J Y` J I t r �. CHECK If BILLING ADDRESS BUSINESS NAME e- �� ^ c r L,& PHONE#) L4 / j /6 I E>R• (I ✓t cork Dq Ho E o�llll ADDRr I n Cb)n c FAX# V 5s ( 1 CITY 5 _I o� C![9W STATE C 2V ZIP �i( 0,-Oz.0 / BILLING TTACKNOWLEDGEMENT: I, 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 JOAQUtN COUNTY Ordinance Codes,Standards, STATE and FEDERAL laws. APPLICANT'S SIGNATURE: 'Z( %A— - Zotkk-1 DATE: PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ If APPUC.4NZLrnottheBn.LtNGPAxrt proof of authorization to sign is required True 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 t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available ant the same time it is provided to me or my representative. PAYMENT TYPE OF SERVICE REQUESTED: miltIL;EIVED COMMENTS: C � OC (�W�tO Vk L NOV 15 2021 SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT ACCEPTED BY: EMPLOYEE#: DATE: 5.-2 ASSIGNEDTO: 1EMPLOYEE#: DATE: J Date Service Completed (if already completed): I , SERVICE CODE: V GI� I Fee Amount: Amount Paid Payment Date I 51-Z I Payment Type 6e r k Invoice# Check# 1013 Received By: EHO 48-02-025 SIR FCAM(Golden Rod) REVISED 11/17/2003