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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID # CHECK if BILLING ADDRE3SO SERVICE REQUEST # OWNER / OPERATOR 1i�, Lrev rl/I Ait,In Y-cr-i CHECK if BILLING ADDRESS FACILITY NAME HOME Or MAILING ADDRESS 11 I SITE ADDDRESS�� 't Street Number Direction t/�f, z O V v ` Streat Name l/ CITY , Gr`KQ!/j C' �C iC•`.0 J city ` [j Zip'Coda HOME or MAILING ADDRESS (If Different from Site Address) 1630 Street Number Street Name CITY #1 �'+ fvCrIL L' STATE t hZIP cl 2-12- `�I `j 'APPLICATION PH0NE#1 Exr. (Zl1`) SBL 12 P APN # LAND USE # PHONE#2 Err. ( ) BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR / / ___/��+ ttt.�"LLL CHECK if BILLING ADDRE3SO BUSINESS NAME �i�/�/f'T/�!2( /�L-� t�lJ✓l C-%fS Gh l7NOYXt GH PONE# p Ems• 6/14" HOME Or MAILING ADDRESS 11 I Ca v� J- !iU' FAx # ) CITY , Gr`KQ!/j Q— C7 STATEG� ZIP BILLING ACKNOWLEDGEMENT: 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 JOAQUIN COUNTY Ordinance Codes, Standards,/STATE and FEDERAL laws. APPLICANT'S SIGNATURE: G �7 �/ /�j�— DATE: _ 2 PROPERTY/ OPERATOR/ MANAGER -0 OTHER AUTHORIZED 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: RECEIGrn COMMENTS: M FEB 0 9 2023 SAN JOAQUIN COUNTY Q— C7 ENVIRONMENTAL HEALTH DEPARTMENT ACCEPTED BY: EMPLOYEE #: •�� DATE: Zcl 23 ASSIGNED TO: EMPLOYEE#: DATE:—t-4 I Z Date Service Completed (if already comp) ted): SERVICE CODE: 62— 1 E: a Fee Amount: Amount Paid g Payment Date G Z>7 ?] Payment Type 5 Invoice # C�eKff J�tp q� 5 '� Received By: EHD 48-02-025 REVISED 11/17/2003 SR FORM (Golden Rod)