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N SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property BUSINESS NAME FACILITY ID # HOME or MAILING ADDRESS � � S �� 6 SERVICE REQUEST # P�s , �� ,�- , CALL (20! sa ooi5MW e OWNER / OPERATOR ^ \ p t , 1 . �•—� y} i ` j „� CHECK If BILLING ADDRESS FACILITY NAME ate* HOUR AN JOAQUIN COUNTY SITE ADDRESSS Soo i �Imet..b'er- l r � ` t Vv t1 Y Direction I Street Name ASSIGNED TO: As 1p Code HOME or MAILING ADDRESS (If Diffe ent from Site ddress) SERVICE CODE: O 1 Street Number Fee Amount: 15 Street Name CITY '�:>& I j �C� S Payment Date STATE ZIP L / L PHONE #1 ExT• 5/ 3 -- 33 v Invoice # APN # 1 11 "� -USa - n.s� LAND USE APPLICATION # PHONE #2 ExT• ( ) 1%a N �a l A t & d , v v BOS DISTRICTLOCATION 3 CODE CONTRACTOR / SERVICE REQUESTOR REQUEST%R rd CHECK If BILLING ADDRESS / � I2 ' ►� l/ BUSINESS NAME PHONE# EXT. HOME or MAILING ADDRESS � � S �� 6 FAX# ( ) CITY STATE ZIP 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 appliccation and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, Standards, STATE d DERAL laws an APPLICANT'S SIGNATURE: r- DATE: O PROPERTY / BUSINESS OWNER;I OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT ❑ If APPLICANT is not the BILLING 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. UESTED:Iter,e j n be �70JmS Jr' Glace. p �1G f YIK CT��1GI RG�+EIVE® CALL (20! JUN 15 2021 FOR INSP ate* HOUR AN JOAQUIN COUNTY REQUIRE ENVIRONMENTAL CCEPTED BY: s i EMPLOYEE #: DATE: Y/ O? ASSIGNED TO: As EMPLOYEE #: DATE: 611 S� /-"? l Date Service Completed (if already completed): SERVICE CODE: O 1 P / E: Ll aD� Fee Amount: 15 Amount Pai iJ�2,t)o Payment Date (O S Z Payment Type Invoice # Check #/2— Receiv d By: EHD 48-02-025 SR FORM (Golden Rod) REVISED 11/17/2003 ))953-7697 'ECTION. NOTICE D.