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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH EPARTMENT t <br />SERVICE REQUEST <br />Type of Business or Property <br />CHECK If BILLING ADDRESS <br />FACILITY ID # <br />PHONE# El, <br />SERVICE REQUESTT# <br />3 <br />HOME O LING ADDRESS <br />y- by 2 231 5 <br />°Ce -t <br />S �;I <br />OW( <br />1 1` J�I / OPERATO �, <br />A Z <br />` <br />So)� CHECK if BILLING ADDRESS <br />\ <br />J'✓�� <br />Y A <br />l' . <br />FACILITY NAME <br />U(I <br />-P, -2H'5S:T <br />i <br />(if already completed): <br />' <br />SITE ADDRESS 1St <br />! \��Cl� J \ <br />n ` <br />Fee Amount: <br />C � Y <br />c, <br />Amount Paid <br />met Number <br />Direction <br />Street Name) <br />CIt <br />Zi Code <br />HOM MAILING ADDRESS (If Different from Site Address) <br />Received By: <br />Street Number <br />Street Name <br />CITY <br />CESTATE <br />17 �L,-AND <br />ZIP <br />PHONE #1 Ezr• <br />APN # <br />USE APPLICATION # <br />PHONE#2 Ezr. <br />I ) <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />CHECK If BILLING ADDRESS <br />BUSINESS NAME <br />PHONE# El, <br />��^ <br />3 <br />HOME O LING ADDRESS <br />FAX# <br />°Ce -t <br />( ) <br />CITY C I a TATE 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 work to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards, TE and FEDERAL laws. <br />APPLICANT'S SIGNATURE: DATE: <br />PROPERTY/ BUSINESS OWNERJ3 OPERATOR/ MANAGER OTHER AUTHORIZED AGENT <br />If APPLICANT is not the BILLING PAR TI: proof of authorization to sign is required Titre <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 the same time it is <br />provided to me or my representative. pAYMENT <br />TYPE OF SERVICE REQUESTED: <br />RECEIVhu <br />COMMENTS: <br />C <br />On <br />rt <br />Nov 0 a 2021 <br />SAN OAQUIN COUNTY <br />NVIRONMENTAL <br />HEALTH DEPARTMENT <br />ACCEPTED BY:WLACO <br />c <br />EMPLOYEE#: <br />DATE: <br />11 <br />ASSIGNED TO: KAdfaon( <br />l' . <br />EMPLOYEE #: — <br />DATE: I� <br />Date Service Completed <br />(if already completed): <br />SERVICE CODE: <br />PIE: <br />Fee Amount: <br />•QU <br />Amount Paid <br />Y �� L _. <br />Payment Date <br />Payment Type <br />Invoice # <br />C,_h"" 13 p l �� <br />Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />