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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> a SERVICE REQUESTL <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 6074110 <br /> NERI OPERATOR Eh <br /> ^ �� �{1i11�� <br /> IUry NAMES CHECK If BILLING ADDRESS❑ <br /> (� <br /> SITE ASoy <br /> DDREss Ls��h�� G533� <br /> - Street Number I tion t N C Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Yt Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 E APN# LAND USE APPLICATION# <br /> 6? b <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> R.EQUESTOR _ I� 4f1, �II ^3 -II� �/� �^ CHECK if BILLING ADDRESS <br /> BUSINESS NAME �'ksf�� n LrI /./1/ LIIA 9`1-ZITVI �PHHONE# � En. <br /> � its <br /> HOME or MAILING ADDRESS `ATC# ., _ <br /> CITY /�v c�To G�,sTATE ZIP C <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: 7 —?-7— Z <br /> PROPERTY/BUSINESS OWNERI,X OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> If APPLICANT is not the BHI"G PAR 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/site assessment <br /> information to the SAN JOAQUIN CouNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at same time it is <br /> provided to me or my representative. gy <br /> TYPE OF SERVICE REQUESTED: JTI�Cel <br /> COMMENTS: ' / AUG 2 0 2021 <br /> SAN <br /> J QUI <br /> HpAC ID1 y�Ec,4,. UNT y <br /> "'Ml;fyp <br /> ACCEPTED BY: 1 1^a EMPLOYEE#: 1 DATE: <br /> A <br /> ASSIGNED TO: n I EMPLOYEE#: t4 DATE: <br /> Date Service Completed (if already completed): SERVICECODE: PIE: Cgo <br /> Fee Amount: Amount Paid15a,� Payment Date Zb <br /> Payment Type Invoice# 130j � Gr Received By: <br /> aw— <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />