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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property �.^ CHECK if BILLING ADDRESS ' FACILITY ID # ^—t-C)\Y V SERVICE REQUEST # - 77 (AV, RECEIVED MAR 13 2023 SAN JOAQUIN COUNTY ENVIRONMENTAL H A] TH DEPARTMENT 4=A@0v?-8(4 CITY 59,W8649cP OWNER I OPERATOR DATE: 3— 1 3 , 2— ASSIGNED TO: L; �Y /�5 CHECK if BILLING ADDRESS FACILITY NAME DATE: 3 _ ` 3 _ 2 SITE ADDRESS 3200"\C7\t) SERVICECODE: bI `ems J Fee Amount: 1 Amount Paid Street Number Dlrection Payment Type/ treet Name Invoice # 1SI Clt ZI Cotle HOME or MAILING ADDRESS (If Different from Site Address) l l-� �l ^-� C --l- , Street Number Street Name CITY 0 STATE � ^ ZIP PHONE#i EXT. APN# LAND USE APPLICATION# IS101 203 - 0D'oo- PHONE#2 EXT. ( ) BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR �.^ CHECK if BILLING ADDRESS ' BUSINESS NAME\\ ^—t-C)\Y V PHONE# EXT. HOME Or MAILING ADDRESS RECEIVED MAR 13 2023 SAN JOAQUIN COUNTY ENVIRONMENTAL H A] TH DEPARTMENT FAX# I ) CITY STATE ZIP 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, STATE and FEDERAL laws. APPLICANT'S SIGNATURE: DATE: PROPERTY / BUSINESS OwNERO, OP / MANAGER ❑ 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 t0 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: PAYMFNI COMMENTS: RECEIVED MAR 13 2023 SAN JOAQUIN COUNTY ENVIRONMENTAL H A] TH DEPARTMENT ACCEPTED BY: \ `_ �r e \1r', EMPLOYEE #: DATE: 3— 1 3 , 2— ASSIGNED TO: L; �Y /�5 EMPLOYEE M DATE: 3 _ ` 3 _ 2 Date Service Completed (if already completed): SERVICECODE: bI PIE: `b02 Fee Amount: MAD0, Amount Paid lS _ Payment Date Payment Type/ Invoice # 1SI ed # Gs$ CA= Received By: 2 / EHD 48-02-025 P� ��OZ I �t SR FORM (Golden Rod) REVISED 11/17/2003 I