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Ile SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />1* SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # <br />SERVICE REQUEST # <br />CHECK If BILLING ADDRESS <br />BUSINESS NAME <br />t4 )Ines tine expose Par�f�rs 1� neeoZed, <br />- <br />OWNER /OPERATOR )'1J <br />Al)S+ Y� 1, <br />CHECK if BILLING ADDRESS �I <br />! 1 / i e <br />HOME or MAILING ADDRESS <br />FACILITY NAME <br />FAX# <br />SITE ADDRESS <br />ACCEPTED BY: L_7z L L <br />CITY OCA <br />STATE 0ZIP r� / t <br />ASSIGNED TO: <br />Gnr— i ”" M <br />DATE: s/a3 " <br />/ <br />SERVICE CODE: / <br />Street Number <br />Direction <br />Sf.1Nam e <br />Payment Date <br />Cit <br />ZI Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />checit # 1 2 Z 5- q I 2"-tl <br />Street Number <br />Street Name <br />CITY <br />STATE ZIP <br />PHONE #1 ExT. <br />( ) <br />APN # <br />1,oidocc% <br />LAND USE APPLICATION # <br />PHONE #2 ExT• <br />BOS DISTRICTCATION <br />Lf <br />CODE <br />Fo <br />( ) <br />q r <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />ro�bu�Ncl d ►n ,, .r, II <br />1 � <br />CHECK If BILLING ADDRESS <br />BUSINESS NAME <br />t4 )Ines tine expose Par�f�rs 1� neeoZed, <br />PHONE #/ p� EXT. <br />CALL(209)953-7697 <br />) b0- Vffi <br />HOME or MAILING ADDRESS <br />FAX# <br />48 HOUR NOTICE <br />ACCEPTED BY: L_7z L L <br />CITY OCA <br />STATE 0ZIP r� / t <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 S�NT <br />COUNTY Ordinance Codes, Standards, STATE an E S. <br />APPLICANT'S SIGNATURE: DATE: •�/� DECEIVED <br />PROPERTY/ BUSINESS OWNER❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT ❑ MAR 2021 <br />If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required TirieSAN JOAQUIN COUNTY <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the proper% l9&YAQk4WcNTAL <br />above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/s1Fe asTstpslif6VTMENT <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: lver l Se.i elc/ks�-cr-op, <br />ro�bu�Ncl d ►n ,, .r, II <br />* <br />COMMENTS: '�JYt} bt- U�'td fr'fl'VeW,iy/ r"y -rob e�15�)YI� �eC1C�1 6Y1eS 8,$/10»y 6-1,fy1 P115- <br />C,ZZ,r1}r1,4bY' avner 4b 46h J i6ft i„sprtbr <br />t4 )Ines tine expose Par�f�rs 1� neeoZed, <br />CALL(209)953-7697 <br />FOR INSPECTION. <br />48 HOUR NOTICE <br />ACCEPTED BY: L_7z L L <br />REQUIRED. M <br />DATE: 3 a3 a j <br />ASSIGNED TO: <br />Gnr— i ”" M <br />DATE: s/a3 " <br />Date Service Completed (if already completed): <br />SERVICE CODE: / <br />P / E: a7C <br />Fee Amount: s Z <br />Amount Paidis 2 _ <br />Payment Date <br />3 2'-Vvv 1/1 <br />Payment Type (� <br />Invoice # <br />checit # 1 2 Z 5- q I 2"-tl <br />Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />