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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 3 3"� <br /> OWNER/OPERATOR CHECK If BILLING ADDRESS❑ <br /> l_.v,\S <br /> FACILITY NAMEr 1 D r�o ` l l79 <br /> SITE ADDRESS C L S `y� S�VCGT MO�CS� �S3 -I <br /> 2,1 Street Number I Direction -r Street Nama City Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> P 0 CSO; s 3 Street Number Street Name <br /> CITY^ r�S`-\�` STATE ZIP , S3 <br /> PHONNEE#f 'C Ex . APN# LAND USE APPLICATION# <br /> PHONE#2 En. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTQR4 ,^ 4 <br /> (^J J Avy—�Y`C1� /\\VC�T�Z CNECK If BILLING ADDRESS <br /> BUSINE NAME TT PHONE# EM. <br /> Ta TE SPOT A -2 20 l $�2-61 <br /> HOME or MAILING ADDRESS FAX# <br /> CITY w,�k\e— STATE ,�, Zip gS32?q <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, STATE and FE RAL laws. q <br /> APPLICANT'S SIGNATURE: DATE: 6-'L-63- 202 I <br /> PROPERTY/BUSINESS OWNERa c OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> If APPLicANTisnoltheBlLlNGPARTYproofofauthorizationtosignisrequired 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, <br /> TYPE OF SERVICE REDUESTED: f IJ 'h /) PAYMENT <br /> COMMENTS: RECEIVED <br /> FEB 0 3 2021 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> ^ 2 HEALTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE#: ! A 37 DATE: 3 -21 <br /> ASSIGNEDTO: Wu <br /> i/7 EMPLOYEE#: "`""3 ✓ DATE: I Z <br /> Date Service Completed (if f allready completed): SERVICE CODE: P E: jUO3 <br /> Fee Amount: 159J Amount Paid _ Payment Date 2'-� / <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />