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'3. SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID # 1, AERVICEREQUEST# Frozen Yo t Shb P"M _ Em HOME or MAILING ADDRESSlQ��i Jennl�e� �y I �R . OWNER II OPERATO CHECK If BILLING ADDRESS WQ� T UPi ..AN JOAOUIN COUNTY, ENVINONMENTAL FACILITY NAME ' HEALTH OgPARTMENT ACCEPTED BY: . y I' L<� G'p SITE ADDRESS r]��y,.-� DATE: 4 _-2 Jackson Rve EMPLOYEE M �sealan Date Service Completed (If already completed): q��iu7 Numlror tNama Fee Amount: - r— Amount Paid s-49 —Payment Zip C ode HOME or MAILING ADDRESS (If DHferent from Site Address) J�ntit{'•eR Invoice # C # ` 2 Street Nu � Deet r. ame CITY �' 060VA I_{) V STATE ZIP I•J 1'/ '/ 20 PHONE #1 ( 20q) MW -2701 APN C LAND USE APPLICATION # PHoNE#Y EST- (20) 909- 9 BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR t,Q� p `'�Q �p y� LtJltll IYU•e Io\V I Ness �QY7Y eqo CHECK rfBILLING ADDRESS BUSINESS NAME I_ ,\ 0 COMMENTS: P"M _ Em HOME or MAILING ADDRESSlQ��i Jennl�e� �y I �R . Fax# 1 1 Cm CaW - STATE IIA ZIP CIF/j, BELL G 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 FEDERAL laws. APPLICANT'S SIGNATURE: � DATE: 41 22_PROPERTY/ BUSINESS OWNERO OPERATOR/MANAGER❑ OTHER AuTHORIzEn 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. TYPE OF SERVICE REQUESTED: Me(,L/ l PIC -"A PAYMENT COMMENTS: APR 2 8 2022 ..AN JOAOUIN COUNTY, ENVINONMENTAL HEALTH OgPARTMENT ACCEPTED BY: . y I' L<� G'p EMPLOYEE #: DATE: 4 _-2 ASSIGNED TO: µVt HLL EMPLOYEE M DATE: .4 ,- 2,9- �Zy Date Service Completed (If already completed): SERVICE CODE: t7 Z3 PIE: Fee Amount: - r— Amount Paid s-49 —Payment Date ?j Payment Type c) Invoice # C # ` 2 ecelved y: EHD 48-02-025 � ZL SR FORM (Golden Rod) REVISED 11/17/2003 i