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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />fyt <br />FACILITY ID # <br />SERVICE REQUEST # <br />,�2vov i� / Ni <br />DEC 17 2021 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />ACCEPTED BY: <br />S� 0 Diq 0 ZS <br />OWNER/ OPERATOR <br />DATE: <br />_ <br />CHECK If BILLING ADDRESS <br />FACILITY NAME <br />y.1 i� �/iii 577 <br />SITE ADDRESS <br />3 <br />Date Service Completed (if already completedr" <br />/Street <br />SERVICE CODE: <br />2 <br />Street Number <br />Direction <br />' Nam/C <br />city <br />Payment Date 12- <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />G I Z' <br />7i d <br />Street Number <br />Street am � <br />CITY <br />_ S zip <br />PHONE #1 EXT. <br />AP N # <br />LAND USE APPLICATION # <br />( 6- ? <br />1� (9 - l 3 / <br />7- --02, 0`d 6 <br />/-/ <br />PHONE #2 EXT. <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />1!r <br />CHECK If BILLING ADDRESS <br />BUSINESS NAME PHONE# EXT. <br />v✓ i --I, (7-o9),S- 2 <br />HOME or MAILING ADDRESS FAX # <br />CITY �r/JQ /� �s-"�1 STATE G04r— 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, STATE and FEDE laws <br />APPLICANT'S SIGNAT DATE; % Z1 <br />PROPERTY/ BUSINESS VNER ❑ RATO ANAGER ❑ OTHER AUTHORIZED AGEN'M—ti� 6;/��1./ <br />If APPLICANT is t to BILLING PARTY, pruof'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 avaiAle>a p– ame time it is <br />provided to me or my representative. Ai �1m1� <br />or --r% <br />TYPE OF SERVICE REQUESTED: S S <br />fyt <br />COMMENTS: <br />DEC 17 2021 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />ACCEPTED BY: <br />EMPLOYEE #: v J ` <br />DATE: <br />ASSIGNED TO: <br />EMPLOYEE #: <br />DATE: <br />Date Service Completed (if already completedr" <br />SERVICE CODE: <br />2 <br />/E: Z Z <br />Fee Amount: <br />Amount Paid <br />O <br />Payment Date 12- <br />Payment Type <br />Invoice # <br />Check # �� <br />Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />