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SAN JOAQ —OUNTY ENVIRONMENTAL HEAL.PARTMENT <br />SERVICE REQUEST <br />Type of Business or Property FACILITY ID # <br />FAOD 20Z 9- <br />SERVICE REQUEST # <br />Ga op ZY1W <br />(---)EA OWNER! OPERATOR <br />vi I S. IY1-1-111(1 V--01 SAIA Pe4, CHECK if BILLING ADDRESS <br />FACILITY NAME p) t 12 <br />\ <br />nc, <br />SITE ADDRESS -7 A 1.-V100 <br />Street Number <br />..-- <br />Direction <br />''Y/Ii-Oti 4.e-6 V r 44/-ar <br />-Street Name <br />‘fli-AQ <br />City <br />9CZO S <br />Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) g 1-1 1 <br />Street Number <br />SVIG-A-I ICUIe...., <br />Street Name <br />CITY s114,..1 STATA_ ZIP <br />Cl 51 -2.• <br />PHONE #1 Exr. <br />111Lp) 4015---la0OLD <br />APN # LAND USE APPLICATION # <br />PHONE #2 Exr. <br />( ) <br />BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR CHECK if BILLING ADDRESS <br />BUSINESS NAME <br />fid <br />PHONE # <br />( ) <br />EXT . <br />HOME or MAILING ADDRESS ---01 FAX # <br />( ) <br />CITY STATE ZIP <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 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 />APPLICANT'S SIGNATURE: <br />PROPERTY / BUSINESS OWNER El OPERATOR/MANAGER 0 OTHER AUTHORIZED AGENT 0 <br />If APPLICANT 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 environmental/sit assessment <br />information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at thep,44it it is <br />provided to me or my representative. <br /> <br />_ - . -A...tilt:4 <br />TYPE OF SERVICE REQUESTED: ,i)(1 Vt1/11 cke I vicoyech Az-8 <br />COMMENTS: .94v,,, 18 2020 <br />#144711%/N CO <br />ii ,C).1,4147, tiAlry <br />AR halt <br />ACCEPTED BY: . ki\gy\AA EMPLOYEE #: DATE: <br />ASSIGNED TO: j I EMPLOYEE #: DATE: <br />Date Service Completed (if already completed): SERVICE CODE: 13 I E: 01? <br />, Fee Amount: (W C4, ,--- Amount Paid Payment Date <br />Payment Type Invoice # Check # Received By: <br />DATE: 2—In —w <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003