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APPLICANT'S SIGNATURE: <br />PROPERTY! BUSINESS OWNER 0 <br />DATE: 9 -29_ e <br />PERATOR / MANAGER 0 OTHER AUTHORIZED AGENT 0 <br />/ <br />41/ _ 44:01 <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property FACILITY ID # <br />nAVD234(02- <br />SERVICE REQUEST # <br />SkabE 4 cici 8 <br />IDAINEA I OPERATOR <br />CHECK if BILLING ADDRESS '2_ I) 1-re 4 670 ir) ? A v 1 i & <br />FAcuir NAME", , ,o c / <br />Oil re c.: A 07 Pe44 v /S. <br />SITE ADDRESS <br />I 235 - Per r 41reet4440- Direction Street Name SIO CAity441 r.,4"- <br />., 947)&0, <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />Street Number Street Name <br />CITY STATE ZIP <br />PHONE #1 EXT. <br />109) 9 S7 — 7 7 1 3 <br />APN # LAND USE APPLICATION # <br />PHONE #2 Exr. <br />( ) <br />EMAIL BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />CHECK if BILLING ADDRESS <br />BUSINESS NAME .--,--.., ) 444 y a .. a ero jv cr ti 0 pedrn 0,74;„ P <br />(z <br />Hoe,..NE/#) 01,57...._ 2 7 j y Exr. <br />HOME or MAILING ADDRSS <br />!:13c 120- /1 A V Y 1 <br />FAX # <br />( ) <br />CITY cle, rk kii STATE 7 <br />, <br />Z I P 95 — 2 0 ? EMAIL <br />BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator Of 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 />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 <br />COUNTY Ordinance Codes, Standard TATE and FEDERAL laws. <br />If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required <br />Title <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the above site <br />address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessmentRitiorMei9...the <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is prit tegrft/51/rny <br />representative. IVn <br />TYPE OF SERVICE REQUESTED: '1 • (-,OnSUL.Q401 on (Pi-ocl.L;kce ) 1 0 '" 4 2024 <br />COMMENTS: SAN JOAQUIN COUNTY <br />M <br />__ENVIRONMENTAL ALTH DEpARTAIENT <br />ACCEPTED BY:13 y t Ctif)11€ M • EMPLOYEE #: DATE: <br />ASSIGNED TO: CA ckcik cLi cx M EMPLOYEE #: DATE: 1_112.q 21-4 <br />Date Service Completed (if already completed): SERVICE CODE: cc (0 PIE: '0003 <br />Fee Amount: ,$A (c 2 CM Amount Paid ( Lc 2 .-- Payment Date ql 2 61244_, <br />Payment Type Ca jA4..., Invoice # Check # Received By: e4.45; <br />END 48-02-025 SR FORM (Golden Rod) <br />03/22/23 <br />PRO51-10 01c12 _)