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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> -�:AW22cpy1 39-mmacog14 <br /> OWNER/OPERATOR C ^ L I A K tq L L i i 'Tl q ,�1 L1TMJ l �`1 <br /> /-I I S f7 I °� l�C � ��/I J'I�9:HECK if BILLING ADDRESS <br /> FACILITY NAME r �f <br /> =00 C TY �j <br /> SITE ADDRESS ?1N, <br /> S u/T / �� NTO� A\U�1J SIJ` <br /> mber Direction Street Name cityZi Cade <br /> HOME or MAILING ADDRESS (If Different fromS.iittet Address) <br /> 5 A/'t — Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#'I Ex*• APN# LAND USE APPLICATION# <br /> (��1 -; -9 z ��m���.7 <br /> PHONE#2 Ex-r. EMAIL j 1 BOS DISTRICT LOCATION CODE <br /> �I� ) GGA >3�3 Na/�i rUS>ry/vim�zz�{j / ��- <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR /L t/r//J/ ✓L� ' / � �1 <br /> /� '/ � „/L-/ 0/- CHECK If BILLING ADDRESS <br /> BUSINESS NAME1:207) h J 7 PHONE# 3 c j ExT• <br /> 6. <br /> HOME or MAILING ADDRESS a (O rftee e /�-JAI Q J) AX# <br /> CITY SF,-2:) �� $TATE/I ZI - ZG 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 /> 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 /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <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: Coll S kibL Qi, jGCI ) <br /> COMMENTS: <br /> JUL 0 6 2023 <br /> &W JOAQUIN COUNTY <br /> E"ONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY:'-ejY 1 C,V1"j EMPLOYEE#:9�G,S DATE:— /(.1,7-'3 <br /> ASSIGNED TO:-DCXf tck EMPLOYEE#: DATE:-4-1(o 1 Z 3 <br /> Date Service Completed (if already completed): SERVICE CODE: P I E: ,�i lUl L <br /> Fee Amount: �I('Z (L Q) Amount Paid cl __ Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 03/22/23 <br />