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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER OPERATOR �� <br /> Lmixl7VGlalkp CHECK if BILLING ADDRESS <br /> FACILITY NAME W Yr k LMf0 0 WO Off ^ <br /> SITE ADDRESS �O�5 <br /> mber Direction V`��/ <br /> I�� " ''StreltNapp <br /> HOME or MAILING ADDRESS (If Different from Site Address) a70O <br /> _t Street Number ID " �i' <br /> CITY e IU M' I e STATE 11166 ZIP 21 <br /> PHONE#}) �y�I Em APN# LAND USE APPLICATION# p' <br /> PIIONE#2' /I IT• @ BIDS DISTRICT LOCATION CODE <br /> CONTRACTOR/SERVICE REQUESTOR <br /> RE BTOiAMyW C)2? 5/� l Er <br /> �� /� //�1 �fI /^ /fin; '/ CpHECK if BILLING ADDRESS <br /> BUSINESS NAME e6m— / ' C 4, �e r t/1 (•I�., /)��/L-"G,l PHla /8 �,9 1 En. <br /> HO MAN DVVD�/�/IJR�SS�� I. t7Tl V�` (/Ll (/,n "I� (A%# �"1 J `„�-t <br /> CITY TATE ✓ 12 zip '2'r1 <br /> �haedu WeOI <br /> a <br /> BILLING ACKNOWLEDGEMENT: 1, 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. <br /> APPLICANT'S SIGNATURE: P / `w k DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> If APPLICANT is not the BILLING PARTY proof of authorizahan to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1,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 t0 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: n G <br /> COMMENTS: R E C E I V E <br /> MAR 10 2021 <br /> SAN JOAQUIN COUN rY <br /> ENVIRONMENTAL <br /> ACCEPTED BY: A e EMPLOYEE#: DATE: <br /> HE LTARTME T <br /> ASSIGNED TO: tYl EMPLOYEE#: DATE: <br /> Date Service Completed (If already completed): SERVICE CODE: PIE: <br /> 2 <br /> Fee Amount: `%2 i Amount Paid !S2 Payment Date <br /> Payment Type Invoice# Check# G d 8 S—� Is Received By: <br /> EHD 48-02-028 ��p�i 4'lo fib SR FORM(Golden Rod) <br /> REVISED 11/17/2003 1 <br />