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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> SR6 3�11111 <br /> J <br /> OWER I OPERATOR <br /> CHECK If BILLING ADDRESS❑ <br /> FACILITY NAME <br /> 41S J <br /> J 0 <br /> SITE ADDRESS <br /> Street Number I Direction I Street Name city Zip Code <br /> HOME r MAILING ADDRESS (f Different from a Address�j2) 1 - <br /> r— � tI <br /> - -PJ Strumber Street Name <br /> CITY W <br /> 0 10 P I Q, ` STATE ZIP <br /> PHONE#) E APN# LAND USE APPLICATION# <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> 22WJ0jm0 <br /> �fj J ® f/�, CHECK if BILLING ADDRESSBUSINESS NAME [' v PHONE# ExT' <br /> t <br /> HOME or MAILING ADDRESS FAX# <br /> CITYt/, 0di <br /> STAT ZIP <br /> BILLING ACKNOW EDGEMENT: 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 /> 1 also certify that I have prepared this application and that tto be performed will be done in accordance with all SAN JOAQUIN l <br /> COUNTY Ordinance Coder,Standards, STA and 1 L laws <br /> APPLICANT'S SIGNATURE: ,Q 00-e DATE;PROPERTY/BUSINESS OWNER OPERA 1 ANA OTHER AUTHORIZED AGENT❑ <br /> IfAPPLICANTis not theBILLINGPARff 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 <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. AA <br /> TYPE OF SERVICE REQUESTED: 1ec Pill <br /> COMMENTS: <br /> FEB 022021 <br /> JOAQUIk CDUN <br /> ii rH EP�RTjk�NT <br /> ACCEPTED BY: Lai EMPLOYEE#: DATE:2L� <br /> ASSIGNED TO: EMPLOYEE#: 3 DATE: <br /> A <br /> Date Service Completed (if already completed): SERVICE CODE: D(P P 1 E: <br /> Fee Amount: v(/ Amount Paid Payment Date aZ a a4 <br /> Payment Typeraj,& Invoice# U Check# CAW Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />