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()(2. 0 S 1 /44 23i s <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property FACILITY ID # SERVICE REQUEST # <br />OWNER / OPEIR , <br />CHECK if BILLING ADDRESS <br />1 4ts Ai PkiRX- e /- v e <br />FACILITY NAME <br />A- $h' kAa( 101/ <br />SITE ADDRESS I l2 L) <br />Street Number Direction <br />g ce- inerrei5NI/at <br />Street Name <br />a c r a r , ercf a <br />City <br />91 5-6 if Zip Code <br />HOME Or MAILING ADDRESS (If Different from Site Address) 5-2 go <br />Street Number <br />Rile' Odk 61,/,. 12 t <br />Street Name <br />CITY STATE ZIP <br />(.1 <br />PHONE #1 Err. <br />( 'f:u ) 2_2_3 - 3 /3 <br />APN # LAND USE APPLICATION # <br />PHONE #2 Err. <br />( ) <br />EMAIL BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR CHECK if BILLING ADDRESS <br />BUSINESS NAME A, 4,0f 01/ 3 I 3 <br /> PHONE # <br />( q/6 ) '7 1 6- <br />EXT. <br />HOME or MAILING ADDRESS <br />4fr 5-2_irr ky 61 v 1 *112 <br />FAX # <br />( ) <br />CITY "N <br />f e( c 0 r, lief <br />STATE 60, A ZIP C7 .reco (557 EMAIL <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 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 FEDERAL laws. <br /> <br />7-2 'i —202 5 APPLICANT'S SIGNATURE: DATE: <br /> <br />PROPERTY / BUSINESS OWNER 0 OPERATOR / MANAGER EIL, OTHER AUTHORIZED AGENT 0 <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 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 air. my <br />representative. PAYMENT <br />TYPE OF SERVICE REQUESTED: MO 61 e- .0(:)6 T OSpe01(._)n (CC nsk.A \ }cAA-to 0 ) RECEIVED <br />COMMENTS: JUL 2 4 2023 <br />-SAN <br />HEALTH <br /> E N Vj ° I ARQDOUEN IPMNAECRNTOTivitjY A LEN NT T <br />ACCEPTED BY: -13v- I C k y)f)e c\A EMPLOYEE #: DATE: "11 224 2-5 <br />ASSIGNED TO: Q 8a9 ? . EMPLOYEE #: DATE: -4 \Z0., \ 2-2, <br />Date Service Completed (if already completed): SERVICE CODE: 0 42/ <br />Fee Amount: SI (0 2_ Amount Paid .4' L 6 c? _ <br />P/E:7 0 03 <br />Payment Date <br />Payment Type vzsA_ Invoice # 9)EO( # /6. 0 Li Received By: ty...1 <br />Title <br />SR FORM (Golden Rod) END 48-02-025 <br />03/22/23