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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> i SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> R s vIG�►� 0 QV3�1 <br /> OWNER/OPERATOR <br /> _' 1L— <br /> CHECK if BILLING AD0RE53O <br /> FAc(u NAME <br /> l <br /> SITE AdDRESS <br /> 0 Street Number Olrectlon SVeat Name Ci \ Zip Code <br /> HOME or M(�AILINrG�ADDRESS (If Different from'tVe Address) <br /> ,zq G 05 r1,/z� t� Street Number Street Name <br /> CITY STATE <br /> a G(, /'11 2 <br /> PHONE#1 Enc APN# LAND USE APPLICATION'# <br /> ((ao ,) - qq-'34 65 <br /> PHONE#2 En. SOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> ,�p CHECK If BILLING ADDRESS <br /> BUSINESS NAME �/�� "� PHONE# Err. <br /> HOME or MAILING ADDRESS FAX# <br /> CITY STATE ZIP <br /> BUJUNG 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 JoAQu[N <br /> CouNTY Ordinance Codes,Standards STAT and FEDERAL laws. <br /> APPLICANT'S SIGNATU DATE: /04 4 <br /> v <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER OTHER AUTHORIZED AGENT❑ <br /> If APPLICANT is not the BHUNGPARTY 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 t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at S e e it is <br /> provided to me or my representative. <br /> PAI <br /> M 1 <br /> RECEIVED <br /> TYPE Of SERVICE REQUESTED: —bfi <br /> COMMENTS: OCT 18 2021 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTi4L. <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE#: '2f 3 DATE: /$ Z( <br /> ASSIGNED TO: r .. EMPLOYEE#: DATE: /a /z) <br /> Date Service Completed (if already completed): SERVICE CODE: O PIE: <br /> I tj 2 <br /> Fee Amount: Amount Paid 5 2 _. Payment Date L <Z <br /> Payment Type Invoice# Check# Received By: All <br /> EHD 46-02-025 SR FORM(Golden Rad) <br /> REVISED 11/17/2003 <br />