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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property r FACILITY ID# SERVICE REQUEST# <br /> '�bo q e F 59 <br /> OWNER/OPERATOR <br /> CHECK It BILLING ADDRESS <br /> FACILITY NAME G.) UGGp, r +O <br /> SITE ADDRESS <br /> J <br /> StreetNumber I OF5 o �21 <br /> Codeect1cn C� x&1. <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> 1Z ' t' <br /> `�V C4 ca ` /Q Street Number Street Name <br /> CITY 0 Q STATE r A ZIP Q l <br /> PHONE41 Ezr. APN# LAND USE APPLICATION# <br /> PHONE#2 Exr. SOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR OC <br /> C�ar�q w D CHECKIf81LLINGADDRE55 <br /> BUSINESS NAMEQ� _ I � [/ � �l PHONE# O I/] T. <br /> 71� IS <br /> HOME Or 11 ING ADDRESS C FA r <br /> 22 <br /> CITY �� STATE CA `5,5 <br /> 203 <br /> 3 <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 1 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: '^ DATE: 1 ! 2Z <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MAN.kGER ❑ OTHER AUTHORIZED AGENT❑ <br /> If APpuCANTisnottheBiLLiNGPA2TYproofofauthorizadontosignisrequired 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 environmentaUsite 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: <br /> COMMENTS: OCT O <br /> 3 2022 <br /> ;� Ury AQQU C <br /> �mDEP�TIIf NT <br /> ACCEPTED BY: / EMPLOYEE#: / 70 DATE: (Q '3 2 2- <br /> ASSIGNED TO: I ,I �e EMPLOYEE#: - �P DATE: 1a/3/2-2— <br /> Date <br /> a 3 2-ZDate Service Co pleted (if already completed): SERVICE CODE: 0' P I E: Ik7�3 <br /> Fee Amount: Amount Paid i Payment Date l d 3 22 <br /> Payment Type �1 Invoice# Check# • Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br /> T <br />