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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWN fpr j ORv 07A/9�5 GC "l/ <br /> v CHECK If BILLING ADDRESS <br /> FACILITY NAM"' /3 <br /> SITE ADDRESS <br /> S <br /> Street Number Diection / S �7 <br /> HO r <br /> INP AOl1RES5.(if rDiffe�t �JsitW ress) <br /> R Ar�t / ter '—street Number / S �o1 <br /> � (At <br /> CITY „ <br /> T TE IP ,l <br /> PHONE#1 E� APN# LANG USE APPLICATION# <br /> PHONE92 EXP. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOFY, CHECK It BILLING ADDRESS <br /> BUSINESS NA7� 5- � � PHO E"T• <br /> HOME �Q�A ADLjF�$S,I �� n _ (A%# ) <br /> CITY v �IY/,4,fT�J/A'"A1 (//'iA'/ — TE ZIP <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 wor!4o be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Stan an E a <br /> APPLICANT'S SIGNATU DATE: <br /> PROPERTY/BUSINESS OWN' OPERATOR/MANA 'R ❑ HE AUTHORIZED AGENT❑ <br /> IfAPP1JCANT Is not the BILLlNC PARTY roof of Go ho <br /> izatio to sign is required Title <br /> AUTHORIZATION TO RELEASE IN ION: When applica e, 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/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 the or my representative. <br /> TYPE OF SERVICE REQUESTED: !!A <br /> COMMENTS: �j 1 <br /> c I,, CEIVCD <br /> l c/k h1gY c C <br /> L 8 2021 <br /> SAN dOAQu,,C <br /> q HEAL iIRO,V&&N7A�1Y <br /> ACCEPTED BY: I'I]per u EMPLOYEE#: DATE: T <br /> ASSIGNED TO: �W EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE• Z P 1 E: <br /> Fee Amount: �� OG' Amount Paid Payment Date 2 <br /> "Jt-lli <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />