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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID # SERVICE REQUEST # Cipg CO q q ci OWNER / OPERATOR CHECK if BILLING ADDRESS r/96 SI /P,4 N 11 FACILITY NAME /1 A AR, przzER'in A- G'OLLF SITE ADDRESS Street Number Direction Street Name City Zip Code HOME or MAILING ADDRESS (If Different from Site Address) Ic7C6' bt.,)sS -r -pot:T Q5-1--- Street Number Street Name Cm( STATE ZIP , /PM./ TLC/4 7 ) 337 PHONE #1 EXT. 9-4) gl5" 7 .00 APN# LAND USE APPLICATION # PHONE #2 Err. 2 15- I 002- EMAIL i3AR'i .Pi 22..AP VAHoo. BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE ROUESTOR REQUESTOR N 4 -7 - A g S c' ii) GIFI CHECK if BILLING ADDRESS BUSINESS NAME •-, i; R., - 0 , , , GRLL PHONE # Exr. 2_01 ( ) g15- /002- HOME or MAILING ADDRESS i 7 6,-,6, wi 5 rioc5k 7 _ 57_ FAX # ( ) crry ,4N1-c/4 in STATE ZIP C? 5-3 3 7 1 EmAn..64 16 . p 1 2 zA (c)04,06.0. 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, ST TE and FEDERAL laws. APPLICANT'S SIGNATURE: DATE: - COM PROPERTY! BUSINESS OWNER121- OPERATOR / MANAGER 0 OTHER AUTHORIZED AGENT 08(1S5,V£5: CA,3A.) If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required Tile 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: Mob i I e. -CIOC-\ EC( Cji l I 1-tj Pians ReA).e.A.A.) rakT 11111GPI I RECEIVED COMMENTS: JUL 25 2023 SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT ACCEPTED BY: c3y .‘0,nrre EMPLOYEE #: DATE: ASSIGNED TO: \i; 6 0,1 EMPLOYEE #: DATE: Date Service Completed (if already completed): 5--(: SERVICE CODE: P / E: (.0(i \ Fee Amount: t 4BG .,../.2 A Amount Paid ( --- Payment Date -/- .2 s 2, 22 ( Payment Type V I Invoice # suecr# /(,, 4e.) ;ca.., [9 Received By:/.f_-7" ‘ffeamr-ILs-r EHD 48-02-025 SR FORM (Golden Rod) 03/22/23