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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> --IR <br /> OWNER/OPERATOR <br /> CHECK if BILLING ADDRE55O <br /> O7'h 6r)4er ( SeS LC <br /> FACILITY NAME <br /> SITE ADDRESS Yo SP •t }� QJ.r\ YYlo..'\�CCsti 15337 <br /> /o� Street Number I Dlrectlon Street Name Ity Me Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) ,71 D f L/NC /7�-1✓l' <br /> 77d7- -P-7=4t AEsL[ Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 ExT• APN# LAND USE APPLICATION It <br /> (204 ) 5bS s/8 LQ <br /> PHONIER Ez. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTORn' pCW ��-1 'T CHECK If BILLING ADDRESS <br /> l_t'lG-r'IF_.S <br /> BUSINESS NAME PHONE# E' . <br /> C I'll En?EIZ 1�215FS LLc. f34 Th�locti Sk V6js,t, c.,.QA c '�-vS S/kite <br /> HOME or MAILING ADDRESS FAX# <br /> 17?0L -)-)De 1—(Ne- D2 ( ) <br /> CITY 1-41 STATE ZIP pf S 3 0 <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 identif d on this form. <br /> I also certify that I have prepared this I tion t at the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Stand s, S E an E RAL laws. <br /> APPLICANT'S SIGNATUR DATE: a•�' ��2 / <br /> PROPERTY/BUSINESS OWNER OPERA OR/ ANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> If APPLICANT is not the BILLING PARTY proof of authorization to sign is required T1 rl e <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. n t /� <br /> TYPE OF SERVICE REQUESTED: 1 IS t/y D' I W-44 T eivT <br /> COMMENTS: D <br /> 2 2021 <br /> Cam U UV" SI 1�V SA/VJ0AQUIJV <br /> ^, , (J y p to 1Y <br /> ACCEPTED BY: / AA 11 �� C , EMPLOYEE#: (r�7 DATE: <br /> ASSIGNED TO: J EMPLOYEE#: 1/ DATE: <br /> Date Service Completed (If already completed): SERVICE CODE: Fib <br /> Fee Amount: Amount Paid J �' Payment Date ), 2--( <br /> Payment Type Invoice# Check# 16100 Received By: <br /> EHD 48-02-025 'n �1 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 �1`U l u I �V 1 <br /> �J <br />