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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> S a 00g-2 �q <br /> bWfVER r PI RATo�zP r <br /> �A1�1 <br /> � b!/JYt O CHECK if BILLING ADDRESS <br /> FAQ 0111 NAM, E R POW, �n w r� I �,' <br /> SIS TE.ADDRESSj S, ��5` p�U �Je f �S3 S f <br /> Li I[ r 1b" ti <br /> Strael Num or Direction Street Name Cit i Code <br /> �JPME Of MAILING AbDRESS (if Different from Site Address) <br /> 46 !'r'POo AVO,O, a Street Number7 Street Name <br /> CITY� STATE J ZIP � {� <br /> 1PRONE11 11 ExT. APN# LAND USE APPLICATION# �1 <br /> PHONE#T EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR 1 SERVICE REQUESTOR <br /> IREQUESTORA /7 <br /> y/I /,n(1 CHECK if BILLING ADDRESS <br /> XBUSINESS_IVAME w j']�-+�� ) 4 PHMr <br /> # EM• <br /> Rows /'�!� f �' 4?0+ ' 232(0 <br /> ft OME-or-MAILING.ADDRESS, FAx# <br /> If/bs SGS�d Aoe__ IYJ <br /> CITY an f_C CG STATE zip <br /> S3 <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 Codes,Standards, ST and FEDERAL la <br /> A-PPLICANT'S-SIGNATURE:�..,� <br /> PROPERTY/BUSINESS OWNER[I O ERATOR/MANAGER OTHER AUTHORIZED AGENT❑ <br /> IfAPPLICANT is not the BILLING PARTY,proof of authorization to sign is required Title <br /> AU-UTHORIZATION TO-REtiEASE 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. <br /> TYPE OF SERVICE REQUESTED: ()J PMMENT <br /> COMMENTS: RECEIVED <br /> JAN 14 2021 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> PAI TH ENT <br /> ACCEPTED BY: EMPLOYEE#: DATE: —! <br /> ASSIGNED TO: EMPLOYEE#: DATE: 1 <br /> Date Service Completed (if already completed): SERVICE CODE: PIE: <br /> Fee Amount: I S Z y Amount Paid s Payment Date <br /> Payment TypeF�ebt' Invoice# Chect#ffliff!UZ 1 03 Received By: <br /> EHD 48-02-025 SR FORM(Golden Rad) <br /> REVISED 11/17/2003 <br />