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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property CHECK It BILLING ADDRESS❑ FACILITY ID # SERVICE REQUEST # BUSINESS NAME j fMFA,MpnE#, - Ezr. t� CJ Ci ,{�CH1E`CCK,Li_ff OWNER/OPERATOR ^ BILLING ADDRESS❑ FAX l C77 I FACILITY NAME LCA �--- �U to G A STATE �I /V zip C� ✓, D SITE ADDRESS 1 ACCEPTED BY: EMPLOYEE #: ^I��'� i C S � CIt'' Von �J�`f 211Qde Z Street Number DATE: Direction Str6et Nam P / E: HOME or MAILING ADD ESS (If Different from Site Add ress)�+//I ��U Amount Paid a _Payment S ee e rM P ✓ U J Street Nu M1bo Street Name CITY(/ o _) ` (-(J� T« zip O C — ( L P40N k E-' APN # LAND USE APPLICATION # (2-6!1) 3-2-1— PHONE #2 ( ) E)d. BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR RE(1UESTO CHECK It BILLING ADDRESS❑ J O� q L 1 w BUSINESS NAME j fMFA,MpnE#, - Ezr. t� CJ Ci 4 Z 2 HOM1�.E,Or MAILINGAj1DRE S ,I ` GJ C 4C. FAX l C77 I .-J, " CITY a';� C STATE �I /V zip C� ✓, D 2 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, ST and FEDERAL laws. xx APPLICANT'S SIGNATURE: DATE: L'. Z1,2 -2— PROPERTY / "—PROPERTY/ BUSINESS OWNER❑ OPERATOR/ MANAGER OTHER AUTHORIZED AGENT 11 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 tiinc it is provided to me or my representative. NA DAVIMGIJT TYPE OF SERVICE REQUESTED: rV RECE IVED COMMENTS: JUN 2 2 2022 SAN JOAQUIN COUN ENVIRONMENTAL HEALTH DEPARTME ACCEPTED BY: EMPLOYEE #: DATE: ASSIGNED TO: EMPLOYEE #: DATE: Date Service Completed (if already completed): SERVICE CODE: P / E: Fee Amount: I !� �-- Amount Paid a _Payment Date (p 02 Payment Type 5 Invoice # C'ac c # y Received By: EHD 48-02-025 REVISED 11/17/2003 SR FORM (Golden Rod)