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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST P R 0 5 3 c) 23? <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> kiwlf FA 00 a a- N I S 0 <br /> OWNER/OPERATOR b CHECK If BILLING ADDRESS❑ <br /> FACILITY NAME hm me NYJ <br /> SITE ADDRESS <br /> � TPPT i A-4b <br /> street Number Ireotio r l• J V i //Col/tle <br /> HOME or MAIG DDRESS (If DI rgDl fro I Add sS) <br /> Jl` Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> ( `�) 612- 0003 <br /> PHONE#2 EXT. BIDS DISTRICT LOCATION CODE <br /> 1 ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR uAyvtT ` <br /> AS . SV r� VLHK LLING ADDRESS <br /> BUSINESS NAME ,� I, L, /�`^'��r) PHONE# Ev. <br /> HOME or MAILING ADDRESS U 1'1 V IJ FAx# <br /> CITY STATE ZIP <br /> BILLING ACKNOWLEDGEMENT: 1, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or roject specific RONINENTAL HEALTH DEPARTMENT hourly charges associated with this project <br /> or activity will be billed to me or y basin d ntified on this form. <br /> I also certify that I have prepared t ' pplica on an that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Stan ,STAT and FE EP <br /> laws. t1 (� <br /> APPLICANT'S SIGNATU E: DATE: 3 6 I Z <br /> PROPERTY/BUSINESS OWNE OPERATOR/M NAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> If APPLICA is not the BILL/NG PAR y proof of authorization to sign is required Title <br /> AUTHORIZATION TO LEASE INFOR ATION: When applicable, I,the owner or operator of the property located at the <br /> above site address, hereby StOorize the r ase of any and all results, geotechnical data and/or environmental/site assessment <br /> Information to the SAN JOAQUIN NVIRONMENTAL HEALTH 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: 77rME <br /> COMMENTS: ` el) <br /> ltio- a- 1 cam, n <br /> JUL 6 2020 <br /> ENVIRO�IN COON <br /> M ry <br /> THDp TAS <br /> ACCEPTED BY: ./� EMPLOYEE#: DATE: 2^_1 <br /> ASSIGNED TO: oL C' I EMPLOYEE Ma�� DATE: CCJJ <br /> Date Service Completed (if already completed): SERVICE CODE: ' Z3 PIE: 1 <br /> Fee Amount: L+S Amount Paid - 5 Payment Date I l0 ZD <br /> .' <br /> Payment TypeCI Invoice# Gheck#— Received By: <br /> EHD 48-02-025 �I- V I l I SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />