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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />CsVooe-� SEVV-:1 <br />BUSINESS NAME_ <br />FACILITY ID # <br />-t oo\g3°10 <br />SERVICE REQUEST # <br />SRi�M6040 <br />OWNER / OPERATOR <br />FAX# <br />( ) <br />I <br />CITY I vU STATE / /� ZIP '2 <br />---6-A0A7—C3CZ CHECK IfBILLING A00RE3SO <br />FACILITY NAMESITE <br />'Cf <br />ZZ <br />ASSIGNED TO: <br />SITE ADDRESS <br />fRESS <br />`� — Street Number <br />\Vw�/r <br />Direction <br />I Street Name <br />CI <br />Zia Code <br />HOME Or MAILING ADDR <br />event f m Site Address) <br />I C� 2— <br />Street Number <br />Street Name <br />CITY <br />DO� <br />1 <br />STATE ZIP u 1 <br />f I <br />PHONE#t En. <br />(Us))-06-$(�(o6 <br />Payment Type l <br />APN # <br />X35 -051 -OB <br />LAND USE APPLICATION # <br />PHONE#2 <br />( ) <br />Ezr• <br />BOS DISTRICT <br />OD <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />CHECK if BILLING ADDRESS <br />REQUESTOR LT�S� �` f"1' A \ �Cz,/\ G�✓i%Z_.Z. <br />BUSINESS NAME_ <br />KbGF:IVED <br />PHONE# Ext. <br />HOME or MAILING ADDRESS <br />-104 W I1 Nn S�— <br />FAX# <br />( ) <br />I <br />CITY I vU STATE / /� ZIP '2 <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, Standar ATE and FEDERAL laws. <br />APPLICANT'S SIGNATURE: DATE: <br />PROPERTY/ BUSINESSOWNER OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT 11 <br />IfAPPLICANT is nor the BILLING PARTY proof of authorization to sign is required Tith, <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 antral jlie sammetir a it is <br />provided to me or my representative. 1'�AY <br />TYPE OF SERVICE REQUESTED: <br />KbGF:IVED <br />COMMENTS: <br />NOV 14 2022 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />ACCEPTED BY:' <br />EMPLOYEE '2 <br />J <br />DATE: l' <br />'Cf <br />ZZ <br />ASSIGNED TO: <br />t N -�, <br />EMPLOYEE #: C C' <br />DATE: (1 1 Z� <br />Date Service Completed (if already completed): <br />SERVICE CODE: (�Gr <br />I <br />P / C)2— <br />)2Fee <br />FeeAmount: I <br />Amount Paid <br />1 <br />Payment Date <br />LI t/ �2 <br />Payment Type l <br />Invoice # <br />C # 5q I : j 9- <br />Received By: <br />EHD 48-02-025 <br />REVISED 11/17/2003 <br />k 0'. 30 0. <br />SR FORM (Golden Rod) <br />rt <br />pr-V5MV 15 <br />