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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# ^�RVIC�E E�Q�S`T1� <br /> I/IAT(CN r—q671— FA C)I- l T `� v� <br /> OWNER/OPERATOR <br /> CA 1-/r0A NlQ � 1-1 ?^ 11� n��y n� CHECK If BILLING ADDRESS <br /> ley <br /> FACILITY NAME 141l`MY i 4v A-rioN ,.5i,110RoR7- t.9C/Ll--r <br /> SITE ADDRESS aDO C7l��p�/ OA (��206 <br /> Street Number Direction J Stre t ame ✓ < /C'it l 7 Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 ExT. APN# LAND USE APPLICATION# <br /> ( ) <br /> PHONE#2 ExT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> 3� /2N/� (/h�)/ S OAA CHECK If BILLING ADDRESS <br /> BUSINESS NAME C /V PHONE# ExT. <br /> JTNc, <br /> HOME or MAILING ADDRESS FAX# <br /> CITY 1 /�i��/j eSTATE ""4 <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 or <br /> activity will be billed to me or my business as identified on this form. <br /> 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 d FEDE L laws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY I BUSINESS OWNER❑ OPERATOR I MA AGER OTHER AUTHORIZED AGENT �� �Lf/yK �/}� 1 j v e, <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 above <br /> site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information <br /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as Soon as It IS available and at the Same time It IS provided t0 me Or <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: PAY_ ryri/ IST <br /> RECEIVED <br /> -4A.1 •� /r /� C i/� .Ti, rr l //1 I C�G/T�/�/�/ <br /> JAN 12 2021 <br /> SAN JOAQUIN OUNTY <br /> ACCEPTED BY: EMPLOYEE#: DATE: DEPA NTAL <br /> TMENT <br /> ASSIGNED TO: Vi EMPLOYEE#: DATE: <br /> Date Service Complete (if already c mpleted): _ SERVICE CODE: Ne P I w <br /> Fee Amount: I Cj 2 OD I <br /> Amount Paid 1S2--- Payment Date I t 2 21 <br /> Payment Type Invoice# Check# ' Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />