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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property evk c-e FACILITY ID # SERVICE REQUEST # SQ Oo g33 i4 0 OWNER / OPERATOR Nr\ SV\ nA GQ/1 CHECK if BILLING ADDRESS /XI FACILITY NAME SITE ADDRESS Direction e coa Pc).--2c °v--c\- Street Name Led', City gez-,2,-D Zip Code Street Number HOME Or MAILING ADDRESS (If Different from Site Address) Street Number I Street Name CALL (209) 993-769 -4 INSPECTION. HOUR NOTICE CITY STATE ZIP FOR 48 LAND USE APPLICATION # !REQUIRED. PHONE #1 Exr. APN # q R600 7 PHONE #2 Exr. ( ) BOS DISTRICT Li LOCATION CODE 99 CONTRACTOR / SERVICE REQUESTOR REQUESTOR CHECK if BILLING ADDRESS BUSINESS NAME PHONE # ( 20C-1 ) 7?.1-c, EXT. 9-9 ..-- HOME or MAILING ADDRESS G COCk_C?r,6S-- FAX # CITY L.0t ‘ v.Lt STATE c R ZIP BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as identified on this form. I also certify that I have prepared this application and that the COUNTY Ordinance Codes, Standards, STATE and rk to be performed will be done in accordance with all ARANWENT RECEIVED DATE: e3-1-9,\ MAR 0 1 2021 APPLICANT'S SIGNATURE: PROPERTY! BUSINESS OWNER arc! OPERATOR / MANAGER 0 N JuAQUIN If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required Title ENVIRONMENTCOUNTY AL AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the propeffiAbItiltaERAIRTMENT above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. TYPE OF SERVICE REQUESTED: Ver ifyaectiit n td .“721-ii 140 1< qflot fil o- )t- ,,f '1 i ivlee)- se ibeit ics 1.-0 COMMENTS: het,-I a doh ft( petwti \i" ST1002d -700 ft4e se p lic I-6de Is do ' Crow the 1.,,,,016,1-101 . -The oda i' h 1117 to the liaue ,i iil ,,,/ ts-';),, e olifect.P). tri j-he see ic t-milk, Ver ,fr that Me Sliiiic 1-4n k k J 11 TO c e i Se a ik (elvicerkk /'he net,/ mach AlDn ACCEPTED BY: '''-.Z.-- EMPLOYEE #: DATE: ASSIGNED TO: D A EMPLOYEE #: DATE: 34/2 / Date Service Completed (if already completed): SERVICE CODE: 0 (...., [ P/E: t4d0,3 Fee Amount: + 1 s- Amount Paid 4 7_5- 2_ Payment Date Payment Type .\ ' Invoice # Urea #1 21 -36 el} 30 8 Received By: OTHER AUTHORIZED AGENT 0 EHD 48-02-025 SR FORM (Golden Rod) REVISED 11/17/2003