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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property P 'T E '-ellr t iA- fT/s Oa FACILITY ID # I ? ) 7 SERVICE REQUEST # OWNER / OPERATOR CHECK if BILLING ADDRESS F i2 r14 C I LL- FACILITY NAME A/ 0 0 d19 ,- icitte_ p,t -tfirie,‘ SITE ADDRESS 1001 Street Number W. Direction LOIN er" faCrAnien.,ta ie-C "104 Street Name tif are) kwi tip•C City '7,3- 2 5-8 Zip Code HOME or MAILING ADDRESS (If Different from Site Address) Street Number Street Name Crry STATE ZIP PHONE #1 Err. (411) APN # LAND IJSE APPLICATION # PHONE #2 Err. ( ) EMAIL pof WOrridivfld96 () 70-,-,iii . cc rI7 BOSI:2;,STRICT LOCAT,cy,ODE CONTRACTOR / SERVICE R QUESTOR REQUESTOR Ill 04 de e r DL;111,, CHECK if BILLING ADDRESS BUSINESS NAME WCad i'}', dirt Pi 1,%61I ,x- PHONE # EXT. (coc ) 91 6. - 2 c); S" HOME or MAILING ADDRESS ) (e)(6 7 9 Al. I-P.4er S ff . ( CA ..."4-1---ic. Fax # CITY STATE Ai zra di:7r) ef94 .. (,-"r ZIP 9 2_ - S EMAIL - Lo r woocaby,aw e 9 ie""zr 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 Of activity will be billed to me or my business as identified on this form. I also certify that I have prepared this applicati d that the COUNTY Ordinance Codes, Standards, ST and FEDERAL S. rk to be performed will be done in accordance with all SAN JOAQUIN APPLICANT'S SIGNATURE: PAYMENT RECEIVED 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 inforrKeicin (1) te2023 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. SAN JOAQUIN COUNT .-1,1 vinuNMEN' TYPE OF SERVICE REQUESTED: .---r---- C:( ":z..-7 C-e_c...4. HEALTH DEPART, COMMENTS: 1---/ I" , ---/S LA A40 , ACCEPTED BY: cf7a.7.(9,.......ea,:, EMPLOYEE #: DATE:_5/17_____3 ASSIGNED TO: . Ct_.--- EMPLOYEE #: DATE: Date Service Completed (if already completed): SERVICE CODE: ......-0 712 / : /6 0/ Fee Amount: .2 Amount Paid 4 (/‘ g ______ Payment Date / 0 2...c....75 Payment Type e Invoice Invoice # g.hecklf i t, 7 V g s---s--177 Received By: DATE: 511/17411- PROPERTY! BUSINESS OWNER El OPERATOR! MANAGER 0 OTHER AUTHORIZED AGENT 0 If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required Title ENT EHD 48-02-025 SR FORM (Golden Rod) 03/22/23