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WE D <br />2022 <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />1114AidcA-c1-uriz_ <br />FACIIJTY ID # SERVICE REQUEST # <br />,-, , 1 f <br />?. - (I t'„ .7") <br />OWNER / OPERATOR CHECK if BILLING ADDRESS <br />FACIUTY NAME <br />---) ;7r (-- <br />SITE ADDRESS <br /> Street Number <br />q 6-- <br />Direction <br />Wk-247-Li /-/ <br />Street Name City Zip CAA ),,r) <br />HOME Or MAIUNG ADDRESS (If Different from Site Address) <br />Street Number Street Name iRjCE — <br />CITY STATE ZIP <br />"R2 4 <br />PHONE #1 Err. APN # LAND USE APPLICATION # SAN jo4 <br />HE4i Tfrfr nOt\IAtl <br />PHONE #2 <br />( ) <br />Err. BOS DISTRICT LOCATION COnt EPA F <br />1 Ct kl <br />RACTOR / SERVICE RE UESTOR <br />REQUESTOR 1,0purbar-rac WA--r: 7 ---PAttel; 7 ->-1' CHECK If BILUNG ADDRESS ri <br />BUSINESS NAME /1/V P-712-02A/tZ <br />PHONE # <br />HOME or MAILING ADDRESS 4_ n _ <br />L i j,L li,.a.,-.._4. hvic E d <br />Fax # <br />( / <br />Cm, oi j 4.'k STATE or zip <br />BILLING ACKNOWLEDGEM NT: I, the undersigned property or business owner, operator or authorized agent of same, <br />acknowledge that all site and/or project specific ENVIRONMENTAL IlEALTH 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 bc done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards, STATE and /tip laws. <br />APPLICANT'S SIGNATURE: DATE: 1911-4.- <br /> <br />PROPERTY / BUSINESS OWNER ATOR / MANAGER 1:I OTHER AUTHORIZED AGENTA' <br />If APPLIC1N7 is not the BILLING PARTY. 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, gcotechnical data and/or environmentallsite 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 />nrCiVi(leil in me or my i <br />TYPE OF SERVICE REQUESTED: Llin LAO lAlkirE,PLIAI.i 04-c-A -..,, <br />COMMENTS: :1 (474,04yr_ Ati,s. 064210 a iv,/ t44444/ a44-‘ warv-icia--),./iy <br />s ' -ion k i Al sel copt c, Je-y-, iikoill iA• .11,14i-b-64,— <br />(Pie cCi--..--i- ,uJ 041 -we 4— tiefrol74)1 <br />tA21)/a/ hAt <br />• <br />DATE: ,2 <br />I/ <br />DATE: 7(1741767/ <br />ACCEPTED BY: ,ir ti let_ EMPLOYEE #: <br />ASSIGNED TO: <br />rtA/Al'eAFA <br />EMPLOYEE #: <br />Date Service Completed (If already completed): <br />_ <br />SERVICE CODE: Z„, ,1'; Pl E: . .--L o I <br />Fee Amount: sgttve--.; t) 4-' I Amount Paid Payment Date <br />I <br />Payment Type, 1 Invoice # Check # H. I 0-7L1 i ,y3--- <br />._ <br />min Received By: i <br />EHD 48-02-025 <br />REVISED 11/17/2003 Ate CAJArrIA, PL-&Pcr& arraPtT <br />c .ovteryi TWA/Ks <br /> <br />SR FORM (Golden Rod) <br /> <br />(31/(_g_pqnv_x_t