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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID # /Y^ r /JA SERVICE REQUEST # BUSINESS NAME S SIV FP DQE) a 8 PHONE# Exr. ) ;;I- OWNER / OPERATOR YAN A-1 FAX# CHECKIf BILLING ADDRESS FACILITY NAME G]] W E E --T —s TI C -TON CITY SITE ADDRESS �-30 y'Z DATE: 4Z G yl C- .'L j� \ O EMPLOYEE #: c Date Service Completed (if already completed): Street Number Direction GG Street Name Fee Amount .UP City ZIP Code HOME Or MAILING ADDRESS (If Different from Site Address) Payment Type i Invoice # 3 b A -v -c 169 Street Numb., Street Name CITY STATE ZIP IJ PHONE#1 Exr. APN # LAND USE APPLICATION # PHONE #2 Eu. BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR /Y^ r /JA CHECK If BILLING ADDRESS BUSINESS NAME S SIV 1 SA -FS rA CT T PHONE# Exr. ) HOME or MAILING ADDRESS FAX# 09 Cr- CCA ( ) CITY STATE 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 work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, Standards, STATE and FEDERAL &Ws. g� APPLICANT'S SIGNATURE: DATE: /2 0 / Z 6 ?- PROPERTY / PROPERTY/ BUSINESS OWNER OPERATOR / MANAGER ❑ — OTHER AUTHORIZED AGENT ❑ IfAppvcANT is not the B/GuNG PARTY proof of authorization to sign is required Tote AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the 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. PAYMENT TYPE OF SERVICE REQUESTED: RECEIVE COMMENTS: MAY 2 8 2021 cv`a(JOFow0e/Shp. JOAQUINTM ENVIRONMENTAL HEALTH DEPARTMENT ACCEPTED BY: � /LLi A [� v�/l. •7 EMPLOYEE #: DATE: ASSIGNED TO: EMPLOYEE #: DATE: Date Service Completed (if already completed): SERVICE CODE: P E:' Fee Amount .UP Amount Paid �s2 Payment Date S' 2 8 Z Payment Type i Invoice # Check # Received By: GO lZ OS 6 EHD 48-02-025 SR FO (Golden Rod) REVISED 11/17/2003