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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID A SERVICE REOUEST 0 <br /> tem..l Ick- r oo.2 eu S' -WS-�820 <br /> OWNER I OPERATOR CML'Ce i18A w�ADOSETS CI <br /> � tJT�tr1rJ rY3C(LLFIn„jJISG `(IfLI(Lf � LA-L <br /> f Aam NAME <br /> 01 A C le-f-T <br /> $iTE ADDRESS 1:;p C N A IZL h rJ (2X� Lf,11 1 i="P I i + - <br /> sN..l Numlw. Ov.ce.n sir.0 Nair c I z. <br /> HOME Or MALING ADDRESS (If Different from Site Address) <br /> 31r.N NYTD.I sbM N.m. <br /> CRY STATE Zip <br /> PHONE 01 En. APN II LAND USE APPLICATION e <br /> 15jC) s,-J - 3 1 Z'c <br /> PHONE 42 En ENAR 90S DIsTHicT LOCATION CODE <br /> I 1 <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REOUESTOR <br /> LNFrx If BLLLiNG AODAE59 <br /> .13 <br /> n I,.,.1 N�t r C.C✓Y-f <br /> BusiNEss NAME PNOHEO Err <br /> 1 rv,1,nN rv�Art V-C]• tt:5c 'L5 - <br /> HoME or MAXING ADDRESS FAX S <br /> C. s R-P, 1 1 <br /> CRY STATE Zr EMAIL <br /> LPrtt.t=r'' CSW+ 4'1(;.37>C <br /> BILLING ACKNOWLEDGEMENT 1, the undersigned property or business owner, operator or authorized agent of same. <br /> acknowledge that all site and,Or project specific E%,tRDNMENTAI 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 cenlfy that I have prepared this application and that the work to be performed will be done in accordance with all SAN U <br /> JOACu . <br /> C�t;r.TY Ordnance Codes,Standards,STATE and FEDERAL laws. <br /> APPLICANTS SIGNATURE: ? .rltr �j'/�Y� DATE: A3- d7- <br /> PROPERTY 1 BUSOCSS OWNER❑ V OPERATOR 1 MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> IfAFRX-ANTisnottheStL^,GPARTY,proofofauthorizationtosignIsrequired Till, <br /> AUTHORIZATION TO RELEASE INFORMATION:When applicable,1.the owner or operator of the property located at the above site <br /> address,hereby authorize the rebase of any and all results,geotechnical data and'or environmentalsite assessment infermnii:n to the <br /> Su+JOACJS.COUNTt E"oKpiEuTAL HEALTH DEPART?"ET as soon as it is available and at the same time n is provided is -- <br /> representative. nA <br /> NT <br /> TYPE of SERYxE REOuESTED: RECEIVED <br /> LarrENTs: <br /> MAR 14 2024 <br /> SAN JOAOUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: Lt r\illair EMPLOYEE tl: DATE. 7J1`21ny <br /> ASSIGNED TO: ° r� EMPLOYEE N: DATE:2 'V2,M11"t <br /> 1 <br /> Date Service Completed (if already completed): SERVICE CODE: OVt_ PIE: <br /> Fee Amount `b2 Amount Paid ` 2 Payment Date :'�'. 1 3. 2 <br /> Payment Type �L Invoice tl eck tl 6s Z-19 I Received By: <br /> EHO 48-02-025 SR FORM IGotoen Roo) <br /> 0171123 <br /> S <br />