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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> :::::I Sk r - <br /> wbLA-'lJL'I <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME L <br /> e d <br /> SITE ADpRESS <br /> C--(( LL Street Number I Direction e w Q: Cit Zit-CboCtle J <br /> HOME or MAILING ADDRF�SS (If Different from Site Address) <br /> 5 Street Number Street Name <br /> CITY T n , STATE ZIP <br /> J lOC�90 /v � <br /> PHONE#1 EX . APN# LAND USE APPLICATION# <br /> � Io2Z- <br /> PHONE#Y En. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> 6 /J 1� CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# Ezr. <br /> (a6c ) <br /> -44 <br /> HOME or MAILING ADDRESS ^ FAX# <br /> J / ri A ( ) <br /> CITY STATE C A ZIP b <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: J DATE: f J D 7— <br /> PROPERTY <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> /f APPLICANT is not the BnyrvG P,tnn' 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 the same time it is <br /> provided to me or my representative. / <br /> TYPE OF SERVICE REQUESTED: /BOO V Q W ett `{1,g RECEIVED <br /> COMMENTS: (�I ,,. ! ,, B 1 ' O ^ , „ JAN 10 2022 <br /> gAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEEM DATE: �I�_22 <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: Q 1 P 1 E: I�� <br /> Fee Amount: AL 152 Amount Paid ( S 2 Payment Date / Zb 2, 2 2 <br /> ir <br /> Payment Type I s Invoice# C # l j�l 2 Received By: <br /> EHD a / SR FORM(Golden Rod) <br /> REVISEDSED 11/1 11117/2003 U 5 <br />