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AN JOAQUIN COUNTV ENVIRONMENTAL HEALTH DEPARTMENT <br /> Type <br /> of Business or Property SERVICE REQUEST <br /> ' FACILITY ID# SERVICE REQUEST# <br /> OWNERI OPERATO��\ \ rlar 001 ,.100 SROOIS584(v <br /> FACILr-Y NAME —�YT \r� �L•g��� CHECIfHBILLING ADDRESS <br /> �S 1 �� <br /> SITEADD E$$ Ikey <br /> atreet Number ` J-1�''-n���� "r7 <br /> HOME Or MAILING ADDRESSDlre<uon Street Name <br /> (If Different from Site Address) <br /> •�i' CITY Sweat Number event Name <br /> STATE ZIP <br /> PHONE#1 <br /> (51 O) 1 C� Em APN# LAND USE APPLICATION# <br /> 1' ` J <br /> PHONE#2 En. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/SERVICE REQUESTOR <br /> . - REQUESTOR <br /> P CHECK if BILLING ADDRESS L�] <br /> BUSINESS NAME , P PHONE 5Laic <br /> 310 <br /> HOME or MAILING ADDRESS FAX# ✓o <br /> CITY STATE 2JJP <br /> BILLING ACKNOWLEDGEMENT: 1, 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 application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Sfandardv,STATEand FED <br /> 'RAL s. q <br /> APPLICANT'S SIGNATUN�RRa�.(��o-Sl0.�- DATE: 1 'a-1 <br /> PROPF,RTY I BUSINESS OWNERq OPERA'I'ORI MANAGER ❑ OTHER AUTHORIZED AGENT <br /> If APPLICANT is not the B111JNU PARTY proofof aHlhorl7,atlon 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 /> P.N"rAL HEAT;III DEPARTMENT 85 5000 as it IS eVallaWe�tpL1,.at1hEe NTtime e it is <br /> information t0 the SAN JOAQUIN COUNTY ENVIRONM <br /> provided to me or my representative. F'H YY fMV(E <br /> TYPE OF SERVICE REQUESTED: D <br /> COMMENTS: OCT 0 9 2022 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONHEALTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE M DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already COmPle[ed). <br /> SERVICE CODE: r� PIE: 1bO� <br /> Amount Paitl <br /> Fee Amount: �Sb �Sb Payment Date q-2q-Z2 <br /> Payment Type Invoice# Chock# V I rl Received By: v <br /> ' <br /> - <br /> EH D 48-02-025 <br /> C O(1F S b Rs H \o4 SR FORM(Golden Rod) <br /> REVISED 11/172003 <br /> _e. <br />