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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />BUSINESS NAME <br />FACILITY ID # <br />HOME or MAILING ADDRESS <br />SERVICE REQUEST # <br />� � T�,�,� <br />FA 0�u i (cL4 <br />SAN joqQU <br />S ROMN5 <br />OWNER / OPERATOR , <br />�0 OR'Tf Z <br />EALTH DEP EAQk <br />CHECK If BILLING ADDRESS <br />FACILITY NAME / /9 7- /il/ �. I J, / c <br />G' <br />Q _ <br />ACCEPTED BY: <br />SITE ADDRESS 22 (3 <br />F <br />m cl k n <br />DATE: W -21 <br />ASSIGNED TO: �. <br />Street Number <br />Direction <br />DATE: <br />Street Name <br />Ci <br />Zip Code <br />HOME Or MAILING ADDRESS (If Different from Site Address) <br />Fee Amount: 1 Z <br />Amount Pa' `S <br />% O cl S <br />Street Number <br />Invoice # <br />Street Name <br />CITY <br />5 0� <br />�a <br />STATE ZIP <br />PHONE #1 Exr. <br />APN# <br />LAND USE APPLICATION# <br />(day) Y77--t-136 <br />PHONE #2 Exr. <br />( ) <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR CHECK if BILLING ADDRESS <br />BUSINESS NAME <br />PHONE # Exr. <br />HOME or MAILING ADDRESS <br />FAX# <br />CITY STATE 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 at the work to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards, STATE an7RAL laws. <br />APPLICANT'S SIGNATURE: DATE: 0 / - 3 t <br />PROPERTY/ BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT El <br />ff APPLICANT isnot the BILLING PAR zs' 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: <br />% 1tiJ <br />�,1/11(j <br />tz„ E' <br />COMMENTS: <br />C V�A(� <br />0 vaitq4 <br />JAN 31 2022 <br />SAN joqQU <br />EALTH DEP EAQk <br />ART,HENT <br />ACCEPTED BY: <br />EMPLOYEE <br />DATE: W -21 <br />ASSIGNED TO: �. <br />EMPLOYEEM <br />DATE: <br />Date Service Co[[[mpleted (if <br />already completed): <br />SERVICE CODE: i <br />P /E: �L <br />Fee Amount: 1 Z <br />Amount Pa' `S <br />Payment Date Z2 <br />Payment Type <br />Invoice # <br />Check # <br />Recei ed By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 0 <br />' I ^' j Z <br />