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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property CHECK if BILLING ADDRESS FACILITY ID # CALL (209)953-7697 FOR INSPECTION. REQUIRED. 4 24-HOUR NOTICE SERVICE REQUEST # H E or MAILING ADDRESS _ 'Z SG ' SSG✓G's DATE: FAX # (217) 3,q- 2"-171 CITY oll r,-,�E ZIPS �j 7 �i l Date Service Completed (if already completed): SERVICE CODE: d r PIE. L/,),) a O NER /OPE ATOR Amount Paid 2- CHECK if BILLING ADDRESS ❑ Payment Type \ Invoice # AGILITY NAME Received By: SITE ADDRESS �1 ^ Fl�e ^2 `� CZip �J Street Number Direction U� `� Street Name'r t� Code HOME or MAILING ADDRESS (If Different from Site Address) �C Street Number Street Name CITY STATE Zip PHONE #1 EXr. APN # LAND USE APPLICATION # (.19-06f) 9 o� 3.,:,3 0q PHONE #2 EXT. 2 47D BOS DISTRICT �j I LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQ ESTOR n'r . CHECK if BILLING ADDRESS BLII ESS NAME'7'C�`C� CALL (209)953-7697 FOR INSPECTION. REQUIRED. 4 24-HOUR NOTICE PHONE# ExT. (2-o-0 3 6 1 — 2. el % (� H E or MAILING ADDRESS _ 'Z SG ' SSG✓G's DATE: FAX # (217) 3,q- 2"-171 CITY oll r,-,�E ZIPS �j 7 �i l 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 Codes, Standards, STATE and JEDERAL laws. _ PAYMENT APPLICANT'S SIGNATURE: DATE:, QCfscwCD PROPERTY / BUSINESS OWNER OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT ❑ If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required Title OCT 19 2021 AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the properVA}P56&60WIF UNTY above site address, hereby authorize the release of any and all results, geotechnical data and/or env ironmental/sitEwgON TAL information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at thrHFRW4uwpkRiMENT provided to me or my representative. TYPE OF SERVICE REQUESTED: COMMENTS: C� F j� l `� CALL (209)953-7697 FOR INSPECTION. REQUIRED. 4 24-HOUR NOTICE ACCEPTED BY: �� L/� EMPLOYEE #: DATE: ASSIGNED TO: F EMPLOYEE #: DATE: I J / 614/ Date Service Completed (if already completed): SERVICE CODE: d r PIE. L/,),) a Fee Amount: Amount Paid 2- Payment Date 1b Payment Type \ Invoice # C ck # 1 3?� q 3 e S -t_— Received By: EHD 48-02-025 SR FORM (Golden Rod) REVISED 11/17/2003