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V SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST sp'6000-$ Type of Business or Property BUSINESS NAME LS ��} G�TDIJ�>`l�Z /♦rL I r G/zNt A c- FACILITY ID # SERVICE REQUESTT # 1,40125%1(p C 6:n1 T bs 1,-- CITY STATE ZIP 6i iy SAN JOAQUIN COUNTY s> 20 U Dj'� D OWNER / OPERATOR _ C�� L � �L {�I (/� LS (�(> M 1 G Al CHECK If BILLING ADDRESS FACILITY NAME C—A L 1 i 6) 3'?—' (1 1S (,PAq I C.. (�!- LTJ Tt ACCEPTED BY: SITE ADDRESS /1I L Q J'i Lsp- S A -t (�flu t_ 6 ID DATE: / s a y � Z 8, Z Street Number Direction P 1 E: a 6,� Street Name C[tv Payment Date Zip Code HOME or MAILING ADDRESS (If Different from Site Addres Check # ) 2_17 5YS7 /,�, q7 Received By: I Street Number Street Name CITY(� Z9 I STATE ZIP PHONE�1 EXT, APN # _-/ 7 LAND USE APPLICATION # PHONE #2 EXT. BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR J� CHECK If BILLING ADDRESS BUSINESS NAME LS ��} G�TDIJ�>`l�Z /♦rL I r G/zNt A c- PHDNE#, EXT• v��l) � 6 "s1'3 HOME Or MAILING ADDRESS LZ fw2 S� C/Z�MrU I` (] FAx# CITY STATE ZIP 6i iy BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as identified on this form. 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 COUNTY Ordinance Codes, Standards,E and FEDERAL laws. APPLICANT'S SIGNATURE: 7 3 ` l- DATE: PROPERTY / BUSINESS OWNER& OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT ❑ If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required d% I'Ll Ac-t;4- Title cz;4- Title AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. TYPE OFSERVIC Yt�. hnpC�+J Y1 b� vI@w ba�hra�wti -�v $E}It s S-�p:�Yl COMMENTS: v( L CALL (209) 953-7 AUG 0 4 2021 alb- �,Y.��s P FOR INSPECTION SAN JOAQUIN COUNTY 24-HOUR NOTICI ENVIRONMENTAL REQUIRED. HEALTH DEPARTMENT ACCEPTED BY: EMPLOYEE M DATE: ASSIGNED TO: TC)G_ EMPLOYEE M DATE: / Date Service Completed (if already completed): SERVICE CODE: i P 1 E: a 6,� Fee Amount: I S Amount Paid/1So2-CID Payment Date Payment Type �-� Invoice # Check # ) 2_17 5YS7 /,�, q7 Received By: I EHD 48-02-025 SR FORM (Golden Rod) REVISED 11/17/2003 697