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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of usiness or Property y FACILITY ID# SERVICE REQUEST# <br /> bD �I �I� o�25t �-14 S Og�c ��� <br /> OWNER/OPERATOR <br /> CHECK if BILLING ADDRESS <br /> FACILITY NAME 1�^ M <br /> SI1E ADDRE$$ t-7 I � ' I �te/II >� <br /> 6lreet AI umber rtcl IIXf 7 ce � / <br /> HOME Or MMUNG ADDRESS, (If Different from SiteA dress) �/Ji1��1 C( /ti 1 -1" <br /> IV! St tNu Number LL(( 'r ( tel,• J/ <br /> CITY STATE ZIP I <br /> RHONEM r __ I EXT. APN# LAND USE APPLICATION# j <br /> 1_ly <br /> RHONE#2 EZ . SOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If RiLuNoAppgEssll <br /> BUSINESS NAME BIOME# E <br /> HOME Or MAILHNG ADDRESS FAx# <br /> GTY STATE ZIP <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 thi0ai on and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,S rannd FEDERAL laws. nAPPLICANT'S SIGNA � � DATE: p�OC �� <br /> PROPERTY/BUS IN Ess OWNER OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ �CS h P NT, <br /> /JAPPUCANrisnottheBmUNGPARrY.proof ofauthorization tosign isrequired Title ECEIVED <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property locT[a <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environmentaYsite asses 2022 <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same'Um#o1LjgobNrr <br /> provided to me or my representative. �V�NOVE"'111 NT <br /> N <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: D <br /> Cc)-PL /96 her n k +-o c�DA-�, -r sef <br /> ('ACM NT <br /> RECEiET Dr7�Lp <br /> ACCEPTED BY: EMPLOYEE#: DATE: JUL LUL <br /> AssIGNED TO: I ` r� � EMPLOYEE#: DATE: �ury WRONMI AL <br /> NJOAGNM ryIUN <br /> IMENI <br /> Date Service Completed (if already completed): SERVICECODE: �2 PIE: QbI <br /> Fee Amount: S b Amount Paid 5 Payment Date '7/-, <br /> Payment Type ;' Invoice# I Check# Received By./-,-' <br /> EHO 48-02-025 1 ZZr� Z-i. SR FORM(Golden Rod) <br /> REVISED 1111712003 <br /> Pr-6 5qti Lo S <br />