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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 I OPERATOR <br /> CHECK If BILLING ADDRESS E] <br /> LISA E Ger <br /> FAC ITY NAME <br /> tol av- e- u L� <br /> SITE ADDRESS Cil r1/ -� q!5 <br /> L 7 �.4 <br /> ZStreet Number DlrectIon Str me �J! CI JCCoVdaT <br /> HOME or MAILING ADDRESS (If Different from Site Address) f`, ems, n - <br /> +L` 1 e--.- Street Number (� StreeE Name <br /> CITY <br /> n a � STATE Z1P <br /> PH0NE#1 ExT• APN# LAND USE APPLICATION# <br /> 120 11 t4 ` cls C7 Z) <br /> PHONE#2 ExT. BOS DISTRICT LOCATtDN CODE <br /> CONTRACTOR 1 SERVICE REQUESTOR <br /> REQUESTOR S CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHDNE# EXT. <br /> ( } <br /> HOME or MAILING ADDRESS FAx# <br /> { ) <br /> CITY STATE ZIP C 1 <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 farm. <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,STATF and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE:, <br /> PROPERTY/BUSINESS OWNERO OPERATOR MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> If.4PPLICANT is not the BILLING PARTY,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 enviromnental/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: Z'Vr <br /> COMMENTS: V60 <br /> MAY °5 2021 <br /> Nor JRa1VMouty <br /> �DEA,gRI. N <br /> ACCEPTED BY: iCA <br /> EMPLOYEE M U DATE: S <br /> ASSIGNED TO: "c f J EMPLOYEEM ;�3 J DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: o i P I E: ! n� <br /> Fee Amount: Glu Amount Paid — Payment Date <br /> Payment Type Invoice# re ,# 2 q 22-a Received By: <br /> FND 48-02-025 SR FORM(Golden Rad) <br /> REVISED 11/17/2003 <br />