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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID # BUSINESS NAMEPHONE SERVICE REQUEST # OWNER/OPERATOR (n Ho o,[ MAILING ADDRESS _ CHECK IfBILLING A7 DDRESSS6fyat FACILITY NAME //�U CITY r TE ZIP �- SITE�DD$ES 1((-0+6Number treet Dirotlon ASSIGNED TO: �i , stre EMPLOYEE #: C Z)LV HOME or MAILING ADDRESS (If Different from Site Address) " Street Number Street Neme CITY Fee Amount: STATE ZIP P�0 ,1 Ext. LI 7 )Z APN If I5a l LAND USE APPLICATION # PHONE #2 Exr. ( 1 Payment TypeO 'lad, BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR ) � CHECK If BILLING ADDRESS BUSINESS NAMEPHONE C EaT. Ho o,[ MAILING ADDRESS _ AUG 2O 2021 $E ully CQU FAX# CITY r TE 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 laws. 1 APPLICANT'SSIGNAT �a rCl 1 Y/T pP� DATE: Q Zd Zo PROPERTY/BUSINESS OWNER OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT❑ If APPLICANT Is not the BILLING PARTY proof of authorization to sign is required Title 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. AbAVa. .._ TYPE OF SERVICE REQUESTED: �(� �Q`/(,(� 1VI Q Yw` • C COMMENTS: AUG 2O 2021 $E ully CQU ACCEPTED BY:. EMPLOYEE #: DATE: ^t G ASSIGNED TO: �i , EMPLOYEE #: DATE: Date Service Completed (if already completed): SERVICE CODE: PIE.: I D Fee Amount: c�?2— Amount Paid I5a l Payment Date L U-✓ 2 I f-yt Payment TypeO 'lad, Invoice# I I I2© Received By: EHD 48-02-025 REVISED 11/17/2003 Fksgils5 SR FORM (Golden Rod)