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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property -- FACILITY ID # f-e E 0 000 g‘l RVICE REQUEST I OD g cS ( i # OWNER/OPERATOR 1--- 1.1 u AN GalaC 0 C) CHECK if BILLING ADDRESS FAcitrrY NAME T14 E Pfl 0 i liV 165 Ctinittitirdf AV e_ Direction SITE ADDRESS Street Name City Zip Code HOME or MAILING ADDRESS (If Different from Site Address) 19)6 Vayt I-) uers CI 14 . Street Number Street Name CITY Ae7 ,p„ e -}..„, STATE ZIP PHONE #1 Exr. ( Z — 3 1 4 — ‘zt- Y ,..._ APN # LAND USE APPLICATION # PHONE #2 Exr. ( ) BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR - ‘.1 REQUESTOR AN C.)( cc - D 6.) TRU CHECK if BILLING ADDRESS a BUSINESS NAME /- n E eHo PHONE # ( 1 Exr. HOME Or MAILING ADDRESS 2._ I-6e k""s C t P ,4, Fax # ( ) CITY APAZSte STATE ( A 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 an FEDERAL I APPLICANT'S SIGNATURE: DATE: i( /2- ) -2_ PROPERTY! BUSINESS OWNER at OPERATOR! MANAGER 0 OTHER AUTHORIZED AGENT 0 g ite• S. 67 '0(/' ,A-er 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. rikT IIIILN I TYPE OF SERVICE REQUESTED: kood Plcwl Ckect( RECEIVED COMMENTS: 6EP 2 1 2022 SAN JOAQUIN COUNT ENVIRONMENTAL HEALTH DEPARTMEN" ACCEPTED BY: ..--"--/*.f- 2-- 7-1 EMPLOYEE #: DATE: ID i/R -1 : C., F-a ii cd ASSIGNED TO ry, EMPLOYEE #: S, 7 E S DATE: ql„a1 Date Service Completed (if already/ompleted): SERVICE CODE: 5D3 P/ E: / (c) 01 Fee Amount: IS 4_(A Amount Paid i.2.76,q, _ Payment Date q/27 I Payment Type \I 1 5 A Invoice # Cleert # /5-6 1 kil a if Received By: el SR FORM (Golden Rod) EHD 48-02-025 REVISED 11/17/2003