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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property FACILITY ID # <br />c A VD(D(1) 11- 5 <br />SERVICE REQUEST # <br />SQ.axbeyi z \ T <br />OWNER / OPERATOR A <br />--- CHECK if BILLING ADDRESS V\iNtrO N i 0 ( (A., <br />FACILITY NAME Ni 0 dr\J II^ s E 2svt t ?A51—C-L <br />SITE ADDRESS ji ord <br />/7/.9 iv A erkt4t Number Direction <br />fiel,n,y,,V 1./v `7 4e 02_ <br />S reet Name <br />LOdf <br />City <br />95;2((n <br />Zip Code <br />HOME Or MAILING ADDRESS (If Different from Site Address) <br />Pi' (), LA,' ,, //lc ir P:,-2/ evell Street Number Street Name <br />-../ C .-#Z Pq57 Vo Crry STATE Zi <br />AO I/ ) <br />PHONE #1 Err. <br />( ) ''CI 7417 3'5/ - <br />APN# LAND USE APPLICATION # <br />PHONE #2 Ex-r. <br />( ) <br />EMAIL BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR . <br /> yyl Co, hi\ Vvk vArck)e_ C2--- --- JP CHECK if BILLING ADDRESS <br />BUSINESS NAME 1 Pti <br />HOME or MAILING ADDRESS FAX <br />/* --7 6 5-eLL, ve^h^-1- f__ <br /># <br />( ) <br />CITY ..r .,0...." I/STATE ZIP q 5:psoy 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 />at the above site <br />jp-i. to the <br />Iv wony <br />I also certify that I have prepared this application a _d that the work to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards, ST nd FE RAL law <br />DATE: <br />OTHER AUTHORIZED AGENT Et <br />APPLICANT'S SIGNATURE„ <br />PROPERTY / BUSINESS OWNER, OPERATOR / MANAGER 0 <br />If APPLICANT /S not the BILLING PARTY, proof of authorization to sign is required <br /> <br />Title <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property locate <br />address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessme <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is pAted <br />representative. <br />TYPE OF SERVICE REQUESTED: C,V10,Yl9t (A OLK)neYS‘C11 0 Jut 3 4 <br />I 423 <br />COMMENTS: SAN JOA <br />eAltliR Ckillii CO 114.7. 0/y4fe UNTy <br />liDEPARNJAL -.,4/Enfr <br />ACCEPTED BY: '6i( i &floe, M EMPLOYEE #: DATE: <br />ASSIGNED TO: ' F(Calui Set_ EMPLOYEE #: DATE: <br />Date Service Completed (if already completed): SERVICE CODE: <br />Fee Amount:$ vo2 go Amount Paid I Cc R ...--- Payment Date --4_ i 3 ‘ \ 2 <br />Payment Type •, Invoice # „Cheak--#-Ce944_e(86e od .ceived By: uw---ii- <br />EHD 48-02-025 SR FORM (Golden Rod) <br />03/22/23 <br />-PR,ON93a