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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property /,}�• CHECK if BILLING ADDRESS FACILITY ID # SERVICE REQUEST # ACCEPTED BY: BUSINESS NAM': C S &MXJ11<y_ O Ezc PHON13Y OWNER / OPERATOR q. FAX# ( ) Fi)P, Date Service Completed (if alreadycompleted): CHECK If BILLINGADDRESS� / f FACILITY NAME C1^S,T 1()6S ryry Fee Amount: S2. ✓ SITE ADDRESS S IInvoice # C}f�Rr7f(EC-� L • Lo P1 ysZy� Street Number Direction Street Name Cit Zi Coda HOME or MAILING ADDRESS (IfDifferentfrom Site Address) d M/// QR l-17 (� n y 7 L, 7 W Street Number Street Name CINF LknD V� Q� STATE ZIP PHONE #1 Em APN # LAND USE APPLICATION # (510) - 8 9z PHONE#2 En. BOS DISTRICT LOCATION CooE CONTRACTOR / SERVICE REQUESTOR REQUEST ......777 L /,}�• CHECK if BILLING ADDRESS FARRale / !' FEB 23 2022 SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT ACCEPTED BY: BUSINESS NAM': C S &MXJ11<y_ O Ezc PHON13Y HOME Or MAILINGADDRESS 1192-8 66�®/ q. FAX# ( ) CITY t-- 1,k7 R () V&r Date Service Completed (if alreadycompleted): STATE ZIP �75—¢ 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 Coder, Standards, Slaws. APPLICANT'S SIGNATURE: DATE: OZ ' ' 2-02-2 PROPERTY / BUSINESS OWNER OPERAOR / MANAGER ❑ OTHER AUTHORIZED AGENT ❑ If APPLICANT is not the B7LLIN PARTY proof of authorization to sign is required 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 OF SERVICE REQUESTED: O VW Iu��FiCsIlmn RN T COMMENTS: FEB 23 2022 SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT ACCEPTED BY: EMPLOYEE#: ASSIGNEDTO: EMPLOYEE#: 7DATE: Date Service Completed (if alreadycompleted): SERVICECODE: IE: 1n Fee Amount: S2. Amount Paid I ✓ Payment Date Z 123122- 322Payment PaymentType Moh, IInvoice # C✓heck # Received By: cu� EHD 48-02-025 SR FORM (Golden Rod) REVISED 11/17/2003 I I I ^