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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property O FACILITY ID # SERVICE REQUEST # Ne }) CALL (209) 953-7697 FOR INSPECTION. 48 HOUR NOTICE REQUIRED. BUSINESS NAME SQ OD? sus r A , HOME or MAILING ADDRESS l) '9CA ASSIGNED TO: F%Gl li ', V FAX # OWNER / OPERATOR DATE: a ( ) CHECK If BILLING ADDRESS FACILITY NAME Game/-- SITE ADDRESS Fee Amount: S6 1 3J , 1 � 1^ �C6 Iv ' 1 Payment Date �n Street Number Direction Street Name Cit Zi Co e`� HOME or MAILING ADDRESS (If Different from Site Address) Street Number Street Name CITY i `. STATE r -A' ZIP U 0 C J I PHONE 1V Ex -r. (131i)19�.6-1o1 APN # 170 Taos LAND USE APPLICATION # PHONE #Z ExT• ( ► BOS DISTRICT L LOCATION CODE 9� CONTRACTOR / SERVICE REQUESTOR REQUESTOR O m h eb./ ndolld CHECK if BILLING ADDRESS CALL (209) 953-7697 FOR INSPECTION. 48 HOUR NOTICE REQUIRED. BUSINESS NAME PHONE # EXT. 26A - �Yto t HOME or MAILING ADDRESS l) '9CA ASSIGNED TO: F%Gl li ', V FAX # h DATE: a ( ) CITY 1 STATE ZIP 9 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. PAYMENT I also certify that I have prepared this application and that the work to be performed will be done in accordance with all SA4ZMEIVED COUNTY Ordinance Codes, Standards, STA and FEDERAL laws. APPLICANT'S SIGNATURE: L�� DATE: �� I/ ZZ� SEP 0 7 2022 PROPERTY / BUSINESS OW OPERATOR /MANAGER ❑ OTHER AUTHORIZED AGENT ❑ SAN JOAQUIN COUNTY If APPLxAAi the BILLING PARTY, proof of authorization to sign is required Title HEALTH DEPARTMENT ARTMENT 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: Ver ! ( 5 e. -it6c ks Cam be S e m h eb./ ndolld COMMENTS:/ V -Z, pt I r" �S V o Cher ew. rl'ess5 CALL (209) 953-7697 FOR INSPECTION. 48 HOUR NOTICE REQUIRED. ACCEPTED BY:�' � L EMPLOYEE #: DATE: J'/,� J ASSIGNED TO: F%Gl li ', V EMPLOYEE #: DATE: a Date Service Completed (if already completed): SERVICE CODE: De I PIE' `i aI V Fee Amount: S6 Amount Paid 5 Payment Date 2,-7-- 7iPayment PaymentType V 1 S Invoice # S>3C<# 2- Received By: EHD 48-02-025 SR FORM (Golden Rod) REVISED 11/17/2003