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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> *0�� I fomwo q3g S 0a <br /> OWNER/OPERATOR <br /> �pp C L <br /> t1 L c.J I r11 � � `�O`�✓/I � CHECK If BILLING ADORESSO <br /> FACILITY NAME � r Y E"� <br /> kto <br /> SITE ADDRESS `i1o. _t l \I�Li 1 t� S {—, <br /> llD Street Number Direction �St�reet Name 9 WJ/ cityZI Colde <br /> HOME <br /> or MAILING ADDRESS (If Different from Site Address) <br /> V S Street Number Street Name <br /> CITY STATE ZIP <br /> S <br /> PHONE#f Enr' APN# LAND USE APPLICATION# <br /> PHONE#2 En. SOS DISTRICT LOCATION CODE <br /> I ) <br /> CONTRACTOR it SERVICE REQUESTOR <br /> REQUESTOR. S'Aa1 ire--� <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# EItT' <br /> HOME Or MAILING ADDRESS ' �� (t FAX# <br /> 3 �XI 't c^n ) <br /> CITY WD STATE OR ZIP aS241 <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 laws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> c <br /> PROPERTY/BUSINESS OWNERW OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT r <br /> IfAPPLicANT is not the BILL/NG 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 environmental/sit <br /> te�e <br /> �""assessment <br /> information t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it Is availaMWENTme time It is <br /> provided to me or my representative. RECEIVED <br /> TYPE OF SERVICE REQUESTED: JUL 2 8 2021 <br /> COMMENTS: <br /> �rpi SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> C�angD, dfarshir HEALTH DEPARTMENT <br /> ACCEPTED BY: V`�� V�� EMPLOYEE#: Ify n DATE: 94 <br /> ASSIGNED TO: EMPLOYEE#: ION <br /> �V DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: `,� n/ <br /> CODE: �W P)E:Il.I"0.�2— <br /> Fee Amount: Amount Paid Payment Date -,7/2 2 <br /> Payment Type L Invoice# Check# I D Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br /> f>ea apo 301 <br />