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Ex-r. <br />PHONE # <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />FACILITY ID # USiness or Property <br /> ti2P)„0 Niti3 <br />FACILITY NAME 9A-v Los <br />Street Number DI ion <br />HOME Or MAILING ADDRESS (If Different from Site Addreso <br />be- <br />APN <br />LoCAT1ON CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR ci:Nty2a0 <br />Dr)-Phipi\V LO5 <br />HOME or MAIUNG ADDRESS kao1 uo way) <br />co()Lt tr <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 <br />or activity will be billed to me or my business as identified on this form. <br />I also certify that I have prepared this applic on and that the work be performed will be done in accordance with all SAN <br />JOAQUIN <br />COUNTY Ordinance Codes, Standard T and EDERAL laws. <br />DATE: 04 (2,0:3 <br />TYPE OF SERVICE REQUESTED: APR <br />Cowen's: C,C1—,11774--K...— A <br />-, <br />/./i'V <br />I <br /> 0 <br />2023 S <br />, <br />A N Jo A <br />Vig8U/N co A L. TH NilizN UN Ty <br />DEPA R ,TA L <br />' MEN T <br />ACCEPTED BY: ' EMPLOYEE #: <br />4 <br />2 7j 3 DATE: 4 7/2-3 <br />ASSIGNED TO: . ) EMPLOYEE #: DATE: <br />Date Service Completed (if already compl ed): SERVICE CODE: --)_3 PIE: /,,,Of• <br />Fee Amount: 21.ce ..... ____ Amount Paid/- zi--6,F, AO Payment Date Li- 72,3 <br />Receiv d <br />/ <br />By:d/r/5— Payment Type ek Invoice # Check # 575 7 <br />EHD 48-02-025 <br />REVISED 11/17/2003 <br />cyttii SR FORM (Golden Rod) <br />OWNER / OPERAT <br />Type o <br />SC2. <br />SERVICE REQUEST # <br />Vt,,r5COP <br />CHECK If BILLING ADDRESS <br />STP-efT <br />PHONE #1 <br />PHONE #2 <br />( ) <br />07 <br />bce_ <br />Strout Nuv <br />(4) STATE <br />LAND USE APPLICATION I <br />BOS DISTRICT <br />ziP ct 5 .5-c? <br />APPLICANT'S SIGNATURE: <br />PROPERTY / BUSINESS OWNF TOR / MANAGER OTHER AUTHORIZED AGENT 0 <br />If APPIKANT is not the BILLING PARTY, proof of authorization to sign is required Title <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the <br />above site address, hereby authorize the release of any and all results geotechnical data and/or environme tal/site assessment <br />information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and Ir4 time it is <br />provided to mc or my representative. IECE;,