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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> =cE CAC-AM SP-o0g34f3I <br /> OWNER/OPERATOR —r <br /> �}NJALI1 S 6 / )A CHECK IfBILLING ADDRESS 0 <br /> FACILITY NAME <br /> PAUL's cC-nc' �M <br /> Si E(ADDRESS M/nt/- �, MI)��/L l�V�. S70CK70) / 01 `5-9oa <br /> "1 �� Street Number Direotlon Street Name Cil ZIP Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> O Street Number Street Name <br /> CITY STATE ZIP <br /> O 70,x/ �Av <br /> PHONE#1 Ex. APN# LAND USE APPLICATION# <br /> (oC JrI D — -790 <br /> PHONE#2 EXT• SOS DISTRICT LOCATION CODE <br /> ( I <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR n //�I L n <br /> 1Y IV :7/'T I S�Tl;q CHECK If BILLING ADDRESS <br /> BUSINESS NAMEPH E# Em <br /> PAUL-Is TC C- ( - 12?- 7�90 - <br /> HOME Or MAILING ADDRESS FAx# <br /> O ALb ( ) <br /> CITY G o Al STAT ZIP 95 a 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 FEDERAL laws. q <br /> APPLICANT'S SIGNATURE: G7 DATE: , C)— <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT <br /> IfAPPLxANT is not the BILLlNCPARTY 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. <br /> TYPE OF SERVICE REQUESTED: n4ftmr <br /> COMMENTS: <br /> CENED <br /> MAK 2 2 2021 <br /> SqN JOAQUIN <br /> NEgL�TF)RONMENTAQL <br /> ACCEPTED BY: EMPLOYEE#: �� DD DATE: Z NT <br /> ASSIGNED TO: Nue—o EMPLOYEE#: OT832 DATE: Zy <br /> Date Service Completed (ifalready completed): SERVICECODE: P/E: <br /> Fee Amount: 't-I -- Amount Paid S2 Payment Date '3121-2- <br /> Payment Type C901, Invoice# Check# Received By:CICp6-� <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />