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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST yO5Lj at Cab,0 Type of Business or Property FACILITY ID # SERVICE REQUEST # Sice)u)?)---i-7-Dbrs OWNER / OPERATOR . G. CHECK if BILLING ADDRESS tio,,,, cy,..e R , ,,,,,, ct.,r- 2 '--• GL`C c.... a FACILITY NAM LT A-C.14 SITE ADDRESS #44 Street Number I k I^ c•ok Direction 1-- Street Name c41/4 City Zip Code HOME or MAILING ADDRESS (If Different from Site Address) *),_ Oci kr'o.,, V--- (jute ° , Street Number Street Name CITY STATE ZIP V-A od Qjc;) PHONE #1 Exr. ( 7`cci 5Fik - 5 q 11 APN # LAND USE APPLICATION # PHONE #2 EXT. ( ) EMAIL BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTQR . \ 05 e 11/4-1, , ,A)C 0 ,4----) is) Ctar C i I C CHECK if BILLING ADDRESS BUSINESS' AME (. 1 • I -(CL.-\ F0<4 PHONE # ( A:C)) EXT. HOME or MAILING ADDRESS --:-1(YA i'q,14_4.,L, (.. FAX # ( ) C ITY Ktvatc. Sit> STATE < z,, ZIP EMAIL 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, STAT F ERAL laws. DATE: 41I0-61 APPLICANT'S SIGNATURE: PROPERTY/BUSINESS OWNER 0 ANAGER 0 OTHER AUTHORIZED AGENT 0 If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required 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: V 66 \ t a Nn (2evte-w I-Ay nnitNT RECEIVED COMMENTS: NOV 0 3 2023 SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT ACCEPTED BY: .1('‘ Ckno-e. '\/1 . EMPLOYEE #: DATE: ASSIGNED TO: v ‘cla k p EMPLOYEE #: DATE: Date Service Completed (if already completed): SERVICE CODE: - , 2- '_.) r 1E: \VIA Fee Amount: -1,4-86, Amount Paid 41 g?e, Payment Date Payment Type V 1(7 1, Invoice # piet<ot 141V U, 1.1?2,Received By74-1---f Title SR FORM (Golden Rod) EHD 48-02-025 03/22/23