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SAN JOAQUIN COUNTY.ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> .� CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS o2� l A/ <br /> Street Number Direction Street Name citv Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) -+s4 PE5 TANA A Ve <br /> Street Number Street Name <br /> CITY _^^ NTC ^ STATE A ZIP_ <br /> 5-336 <br /> PHONE#1 I,'l 1 G�—f t ExT• APN# LAND USE APPLICATION# pl <br /> vo9 ) 101 -.2+0 - 16 <br /> PHONE#2 EXT• BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> Do N e—(4 <br /> (r�.5 N Ev CHECK if BILLING ADDRESS <br /> BUSINESS NAME ('"1 PHONE# ExT' <br /> HOME or MAILING ADDRESS FAX# <br /> Is o ( ) <br /> CITY 1-0• le— STATE ZIP <br /> 1539( <br /> BILLING ACKNOWLEDGEMENT: 1, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project specific ENVIRONMENTAi..HEAL.Tii DEPARTMEN'r 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 1 have prepared this applic&1on and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards, S' and FEDWa laws. <br /> APPLICANT'S SIGNATURE: D;aTrEp: 6/B/oZD <br /> PROPERTY/BusINESS OWNER❑ OPERATOR/',MANAGER ❑ THERAUTHORIZEDAIGENT LI <br /> .6(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/site assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTIi DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: PI-A l l G yEGK FOA 5 S �� <br /> COMMENTS: I VZD <br /> JUN 8 2020 <br /> SAN j0AZAfQU/N C <br /> HE,gLTN pEPMENTq�1Y <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: G \ /p EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): �l SERVICE CODE:1Z P I E: <br /> Fee Amount: Amount Paid 3oC{. ___. Payment Date (Q $ <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />