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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> tac 0 ��U'o-% 1s3bG SQp� gaqq <br /> OWNER I OPERATOR '^)/t y� <br /> l \ l N`��1 ,1 1 \P 2S-1 SS CHECK If BILLING ADDRESS <br /> FACILITY NAME `l�(��tAria cn a <br /> maL <br /> SITE ADDRESS , ` <br /> Street Number Direction treat Name City Zip Codo <br /> HOME or MAILING ADDRESS (If Different from Site Address) r n ' T-o\'ty Ju e <br /> Street Number etreet Na �C-J` ✓ f���' <br /> CITY c-�\v`\ STATE ZIP O <br /> PHONE#1 Exr. APN# LAND USE APPLICATION# <br /> (2-)52-9-q6 <br /> PHONE#2 ExT. BOS DISTRICT LOCATION CODE <br /> CZ-M )321 –b IT <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> HOME or MAILING ADDRESS FAX# <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 Coder,StandV, STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: � A In 1 P` 9 I I I t4—% DATE: <br /> �V- ' <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> If APPLICANT IS not the BILLING PARTY proof of authoriZatioli 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 HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. Q ' PAYMENT <br /> � V <br /> TYPE OF SERVICE REQUESTED: �y 6(Lt✓C. 1 Vl <br /> COMMENTS: DEC 10 2020 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: 1 �1A 14 n n . - EMPLOYEE#: DATE: '1 <br /> ASSIGNED TO: /C ,//rte°�(Jt/t, EMPLOYEE#: DATE: I -7 <br /> Date Service Completed (if already completed): SERVICE CODE: P/E: v// <br /> V <br /> � <br /> Fee Amount: _ mount Paid F �Z Payment Date <br /> % O <br /> Payment Type GS Invoice# I Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br /> FV�01 <br />