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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> SQ o o2y�-yq <br /> OWNER/ OPERATOR oC ^ Grp Q <br /> `] ) Gt (�(�(C/{�.(� CHECK If BILLING ADDRESS 0 <br /> FACILITY NAME <br /> d41VIA 0 Fin av✓A5 <br /> SITE ADDRESS + MGl i2G <br /> Street Number Direction Street Name <br /> HOME Or MAILING ADDRESS (If Different from Site Address) �_ ci zi code <br /> 2� I NLU t� /(•,nom <br /> CITY Street Number Street Nama [ L <br /> STATE ZIP 7 T <br /> PH0NE#1 Ex . APN# <br /> LAND USE APPLICATION# <br /> PHONE#2 7 L Ex . BOS DISTRICT <br /> ( ) LOCATION CODE <br /> REQUESTOR <br /> CONTRACTOR / SERVICE REQUESTOR <br /> 0d—A/` —A4 <br /> � e V4r, -� <br /> /�1Q t �o l I CHECK if BILLING ADDRESS <br /> BUSINESS NAME ~\a ' rrUi/L-5 <br /> HOME or MAILING ADDRESS -2,01 (WAve—C /'�"� FAX# <br /> CITY STATE C zip /:TtiJ .T1 <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,Stand ds, STATE and FEDERAL <br /> I laws. <br /> *APPLICANT'S SIGNATURE IC ��„ Inl��� DATE: ZZ <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> If APPLICANT is not the B1mNG PARTY 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: J e l(i.Q f,VI�C3 T <br /> COMMENTS: <br /> JAN 2 0 2022 <br /> � <br /> JOAQUIN <br /> N CO <br /> UNry <br /> _ ^ HEALTH DEENTAL <br /> PAR M NT <br /> ACCEPTED BY:! A/V ` EMPLOYEE#: DATE: <br /> ASSIGNED TO: 111 _ EMPLOYEE#: DATE: <br /> Date Service Co pleted (if already completed): SERVICE CODE: PI E: 1006 <br /> Fee Amount: 5-Z Amount Pai /S ai bd Payment Date 22 <br /> Payment Type Invoice# Check# Recei ed By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 R-o (;Ll I q(S s <br />