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r i SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID If SERVICE REQUEST# <br /> ::1 S 6&A r <br /> OWNER/OPERATOR ^ /HECK If BILLING ADDRESS <br /> % oLi <br /> M 6 V-1 o a2- e <br /> FACILITY NAME ;Io lerne_ ���cz / �v�.,t; c� Lt <br /> 4 IT/1C' / <br /> /y v L�c�.v <br /> SITE ADDRESS <br /> J V. <br /> StreetNumberDirection \Street Name � City � Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Eo / <br /> k^a''"'AI(' G L Q FZ'•L Street Number Street Name <br /> CITY j TATE ZIP <br /> 05-z o <br /> PHONE#1 EXT' Tp—N# / LAND USE APPLICATION# <br /> (yt� >l�rv�► -rr3� <br /> PHONE#2 EXT. OS DISTRICT/ LOCATION CODE <br /> ( ) \ / <br /> CONTRACTOR / SE VICE RE UES R <br /> REQUESTOR \ / <br /> 3t:J(}.n. Pan Ll(o CHECK if BILLING ADDRESS <br /> BUSINESS NAME /^ / PHONE# EXT. <br /> T,\uD L Ll( o ` \ / (9L6 )(,ce9-112,;-, <br /> HOME or MAILING ADDRESS I FAx# <br /> �q 0c'v� L-4 \ I <br /> CITY t� / ` $ITATE C l.� ZIP <br /> BILLING ACKNOWLEDGEMENT: I, �ry�e undersigned property o business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project speblfic ENVIROI,? TAL HEALT DEPARTMENT hourly charges associated with this project <br /> .or activity will be billed to me or my busine4 as identified on this form. <br /> I also certify that I have prepared this applicat\n and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Coder,Standards, STAT d1 laws. <br /> APPLICANT'S SIGNATURE: DATE: /*— Zo'o <br /> PROPERTY/BUSINESS OWNER❑ OPEIAT /MANAGER ❑ OTHER AUTHORIZED AGENT 11 <br /> If APPLICANT AS not the BILLINGPARTP 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 /> inforinlation to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as Soon as it is available and at the sante time it is <br /> provided to me or my representative. ` <br /> TYPE OF SERVICER CoosL0 _ r <br /> COMMENTS: RECEIVED <br /> NOV 12 2020 <br /> SAN JOAQUIN COUNTY _ <br /> ENVIRONMENTAL <br /> �t <br /> /� <br /> ACCEPTED BY: A Col V <br /> EMPLOYEE#: / t DATE: 11 <br /> ASSIGNED TO: v EMPLOYEE#: r - DATE: <br /> Date .Service Completed (if already completed): SERVICE CODE: OI o P/E: �f� <br /> Fee Amount: '�,. 'VV Amount Pai /sa �D Payment Date <br /> r ll <br /> Payment Type Invoice# Check# 6 13 Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />