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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID # SERVICE REQUEST # BUSINESS NAME 9Qoo g g C1 C1 C) FS / /V T/ L R�NME o) sa OWNER/ OPERATOR ACCEPTED BY: c�'T�^� L FAX# 1WR .,4A1rNoti / O 164I !ri-H D i rn CHECK If BILLING ADDRESS K 51VAr FACILITY NAME EMPLOYEE #: CITY SITE ADDRESS -,2 7 ,lo o ZIP /j C�y�/ ,1AR-1 A1D.c{-E 3 Fee Amount: * � D-1 Street Number Direction Street Name c1tv Zip Code HOME Or MAILING ADDRESS (If Different from Site Address) l67o /Number Refer &1,4 1? E /-,4 NE, SW /TE,4 Received By:/ Street Street Name CITYSTATE o C ZIP ,-,,A 9Sa o PHONE #1 EXT. APN # LAND USE APPLICATION # PHONE #2 ( ) EXT. BOS DISTRICT LOCATIO CODE Cr CONTRACTOR / SERVICE REQUESTOR REQUESTOR CHECK If BILLING ADDRESS O A/ BUSINESS NAME PHONE# EXT. R�NME o) sa HOME or MAILI DDRESS ACCEPTED BY: c�'T�^� L FAX# EMPLOYEE #: DATE: 71141 / ASSIGNED TO: fil JS EMPLOYEE #: CITY STATE(�7A ZIP /j C�y�/ 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 ap i ation and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, Standards T TE and F ' L laws. APPLICANT'S SIGNATURE: DATE: a PROPERTY / BUSINESS OWNER ❑ OPERATO / 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& same time it is provided to me or my representative. x'4y PAI�. TYPE OF SERVICE REQUESTED: 5 S C� /L y/ V �C��l y f il, COMMENTS: 14 � 2022SAN d�o0UNIyAH R�NME EpcNT ACCEPTED BY: c�'T�^� L EMPLOYEE #: DATE: 71141 / ASSIGNED TO: fil JS EMPLOYEE #: DATE: 3 /° Date Service Completed (if already completed): SERVICE CODE: l 3 P / E: Fee Amount: * � D-1 Amount P Jam` Payment Date Payment Type /"71 Invoice # Check # 3 Received By:/ EHD 48-02-025 SR FORM (Golden Rod) REVISED 11/17/2003