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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST eQ 2-S o007-0 <br />Type of Business or Property \:_-6-ock iNr_*AL)c FACILITY ID # SERVICE REQUEST # <br />SCZCIxDB-1- Be‘ <br />OWNER/OPERATOR foauR -, S1-1 CHECK if BILLING ADDRESS <br />FACILITY NAME ? U‘r\'') G9si <br />SITE ADDRESS '7) F 5 <br />Street Number <br />No-1---tr) <br />Direction <br />T-6 ( cc.i l)1 ti 4 <br />Street Name <br />"Fyn cik <br />City <br />q <br />Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />'.-i -1-OCTIi‘, n r-)- 1 (.: \ Street Number Street Name <br />CITY STATE ZIP <br />PHONE #1 #1 EXT. <br />( (Y(DL1) ) 6 1 •»90(-k <br />APN # LAND USE APPLICATION # <br />PHONE #2 Exr. <br />( ) <br />EMAIL BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />cox- v C <br />CHECK if BILLING ADDRESS El <br />BUSINESS NAME PHONE # EXT. <br />( ) <br />HOME or MAILING ADDRESS FAX # <br />( ) <br />CITY STATE ZIP EMAIL <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 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, Standards, STATE and FEDERAL laws. <br /> <br />DATE: NV"- C. \ -17 <br />PROPERTY! BUSINESS OWNER 0 OPERATOR / MANAGER 0 OTHER AUTHORIZED AGENT 0 <br />If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required <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 assessment information to the <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is provided to me or my <br />representative. <br />TYPE OF SERVICE REQUESTED: M,ç ex% \ S u_Q 40Jci or) <br />4,-1 r AAH „,.., _ <br />Iii CA.1.1417. 41/ED COMMENTS: p‘ cit:r041.3 1:\,..ev , 0 tAst Li tze 43.‘terecc , n scuiram en i..c..) cours.„4,1/41 <br />di f4R 1 <br />3 2024 Jaic? <br />ii4:44611.4;-calozvumliV,2 1,4,71, "u PA A, 7411-00. <br />ACCEPTED BY: S .42) a l 1 Loa jot ft EMPLOYEE #: DATE: 3./3. &4 <br />ASSIGNED TO: V. p _ i <br />Ca r0.7_0. <br />EMPLOYEE #: DATE: S, I 3. a4 <br />Date Service Completed (if already completed): SERVICE CODE: (3 (0 i PIE: i 03 ll() <br />Fee Amount: $ (Co a Amount Paid_ /6,22 . (Do Payment Date <br />g ,scy-f-ro <br />37/ <br />Received <br />3 72._ <br />Payment Type 2f -ea,1 ---t- Invoice # Check # 17 ---0 By:a7Z5—r- <br />APPLICANT'S SIGNATURE: I <br />Title <br />SR FORM (Golden Rod) END 48-02-025 <br />03/22/23