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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> T-OJ -(V,Uc,Y S - — <br /> OWNER/OPERATOR \I ,it,', -h I- <br /> 1UYy YJ(ltulls'1 A i e)L(j ((AStYl) CHECK If BILLING ADDRESS� <br /> FACILITY NAME Iotl �V1A' EG AtteCO� <br /> SITE ADDRESS W q ,,11 <br /> ZCovU SlreetNumber Diradlon NUPCalh9 SreetName �C Zip Code <br /> HOME Or MAILING ADDRESS (if Different from Site Address) <br /> `V�5 t li(.I�PXl1L Y Street Number Street Name <br /> CITY STATE ZIP <br /> SkU0whr\ 031 a 2G"I <br /> PHONE#1 En. APN# LAND USE APPLICATION# <br /> (ZO1 %V1 <br /> PHONED FM. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR ,,((y�,�� <br /> VUY1� Y�V.'�S'ri1 CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> TiM4,U �one EL Lre(A ( zm )ya3 <br /> HOME or MAILING ADDRESS FAX# <br /> �16�r� 11tc1U1t�K �✓• ( ) <br /> CITY STATE R Zip? <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 S. <br /> APPLICANT'S SIGNATURE: t'y: DATE: <br /> PROPERTY/BUSINESS OWNER 3 OERATOR/MANAGER ❑ OTHER AUTRORizED AGENT 11 <br /> IfAPPLtCANT is not the B/LUNG PARYT 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: <br /> COMMENTS: RECEIVED <br /> MAY 14 2021 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY:� `� ` �-t EMPLOYEE#: DATE: 1L <br /> ASSIGNEDTO: EMPLOYEE#: DATE: �♦�, \ Z <br /> Date Service Completed (if already completed): SERVICE CODE: l PIE: <br /> \ <br /> Fee Amount: 2 Amount Paid 15 Z Payment Date <br /> Payment TypeLEI Invoice# Check# Received By: <br /> EHD 48-02-025 SR F M(Golden Rod) <br /> REVISED 11/17/2003 <br />