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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />type of Business or Property <br />/ ::7—;�/ <br />FACILITY ID # <br />BUSINESS NAME <br />1SE�iRVrIC'EIREQUEST # <br />--q <br />HOME or MAILING ADDRESS / <br />(P <br />FAX # ) <br />OWNER / P TOR <br />-1�©� �! �� ��; �,.? <br />"t GGG <br />CHECK If BILLING ADDRESS ❑ <br />���1 <br />FACILITY NAME <br />C� <br />SITE ADDRS//�j <br />`r " r.3umber <br />Dir n <br />Street Name <br />ity C <br />i Zi Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />Street Number <br />Street Name <br />CITY <br />STATE ZIP <br />PHONE#1 EXT, <br />(M) <br />APN # <br />LAND USE APPLICATION # <br />& lq <br />—�;ra-��� <br />PHONE#2 EXT. <br />( )17 <br />BIDS DISTRICT <br />LOCATION CODE <br />C4 <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR % <br />VVV ( <br />CHECK If BILLING ADDRESS ❑ <br />BUSINESS NAME <br />NE z` �^ ✓�t EXT. <br />HOME or MAILING ADDRESS / <br />(P <br />FAX # ) <br />CITY <br />STA ZIP 7 <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 this applic and that the work t e erformed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards, ST d FEDE`�aw �J ,et�r!', 2 <br />APPLICANT'S SIGNATURE: �� DATE: `"� `^� �C/ _ <br />PROPERTY / BUSINESS OWNER OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br />If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required Title <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the <br />above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment <br />information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br />provided to me or my representative. <br />TYPE OF SERVICE REQUESTED::f t e, b i 1 }y � i'ry &I, i <<� fe Loci (� I r,5s t� Cd � � � —ENT <br />COMMENTS: t t l s f V C;�y PY�G" I I P. �I to �Ct SYt' r E/ �1 f7 I iC C�Y1 E® <br />JUL 0 l 2022 <br />NJ Ul <br />HON �� <br />���N7Y <br />ACCEPTED BY: — ZEMPLOYEE #: DATE: 7 7 <br />ASSIGNED TO: / EMPLOYEE #: DATE: <br />Date Service Completed (if already completed): SERVICE CODE: c, 3 P 1 E: <br />-'94o'3 <br />Fee Amount: 4 9 � 9 Amount Paid Payment Date �- Z Z <br />Payment Type Invoice # Check # Received By: <br />L/ <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />