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a SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID If SERVICE REQUEST# <br /> :: I I 5olvs3e��'3 <br /> OWNER OPERATOR Duo <br /> U IV F n,,VI D u o Na- CHECK if BILLING ADDRESS <br /> FACILITY NAME Cuns„j JC1t,'ne}p <br /> SITE ADDRESS 6 l� V�JG IJCm. hwadvlo yah I -f kd-o n 9524 <br /> Slreel Number Direction Street Name CI 21 Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) l I wlj S pul <br /> Slreel Number Stre Name <br /> CITY 4,0N STATE Cit ZIP <br /> PHONE#1 ET• APN# LAND USE APPLICATION# `7 <br /> (20 ) us <br /> PHONE#Y ExT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE RE UESTOR <br /> REQUESTOR DI Lr 1�n1S Kk <br /> pbe CHECK If BILLING ADDRESS <br /> BUSINESS NAME su�s� em PHONEII(J,' 4 ExT• <br /> HOME Or MAILING ADDRESS1 FAX# <br /> ( ) <br /> CITY STATE ZIP <br /> j10 ), <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 IOAQUIN <br /> COUNTY Ordinance Codes,Standards,STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE; <br /> L—PROPERTY/BUSINESS OWNER❑ TOR/MANAGER ❑ OTHER AUTHORIZED AGENT 13 <br /> If APPLICANT is not th BI�LiNG <br /> PA 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 t0 the SAN 70AQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. ry P <br /> TYPE OF SERVICE REQUESTED: �n RE <br /> COMMENTS: <br /> APR 12 2021 <br /> q��ROUIN CpUN <br /> NeALNDe" �IY <br /> ACCEPTED BY: r�j EMPLOYEE M DATE: <br /> ASSIGNED TO: EMPLOYEE M DATE: Z `J <br /> Date Service Completed (if already completed): SERVICECODE: P1 E: 11fol <br /> Fee Amon Amount Paid D Payment Date <br /> Payment Type GII� Invoice# Check# ZZ Receiv d By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br /> PtOS-f�5�°f <br />