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SAN JOAQUIN COUNTY EwtRoNMENTAL HEALTH DEPARTMENT copy <br /> SERVICE REQUEST <br /> Type of Business or Property n ���(�} FACILITY ID# SERVICE REQUEST# <br /> Wkur'Wm �C lfi1 T �C S RQJ 8 5 �5 <br /> OWNER/OPERATOR <br /> CHECK if BILLING ADDRESS <br /> L <br /> F <br /> L-6/� C/✓Jy 2�1/ <br /> D <br /> ME Or NG RES`S from H Diffe errt ite Add ) <br /> ` Stnud Number Na <br /> Cn`� 0 (\ � STATE ^ P <br /> V V / �L <br /> PfIDtJ�#I ';o� qla-W�7 APN# LAND USE AP%JCAnoN# <br /> PRONE#2 ET- SOS DISTRICT LDCAnDN LADE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE# E[ - <br /> HOME or MAILING ADDRESS FAX# <br /> 1 ) <br /> CITY STATE ZJP <br /> BH.LING ACKNOWLEDGEMENT: 14 the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project specific INviRoNMENTAL 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 pli n and that the work to be performed will be done in accordance with all SAN JOAQUI N <br /> COUNTY Ordinance Codes,Stand TA LED <br /> APPLICANT'S SIGNA DATE: I <br /> PRO /Buslp _SS ERATO AGER ❑ OTHER AUTHORIZED AGENT 11is not the B=G PAnzY 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 enviroDmental/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. PA <br /> Ymrzhrp <br /> TYPE OF SERVICE REQUESTED: dd su +a ECE1V <br /> En <br /> COYYENTS, <br /> SEP 13 2022 <br /> SAN JOAQU/N <br /> NSN-rl.I DEP HTM <br /> ACCEPTED BY: J C. EMPLOYEE#: �(+(o� DATE: V 13 as <br /> ASSIGNED TO: 1). A EMPLOYEE#. O 'l Ci DATE. q/13/9q 13 '1q <br /> Date Service Completed (if already completed): SERVICE CODE: Sc 0(D 1 1 <br /> PIE. I (Poa <br /> Fee Amountmoun <br /> It 15(D. QQ Amount Paid 1�. Payment Date <br /> Payment Type Invoice# Cheek# ` Received By: <br /> EHO 48-02-025 SR FORM(Golden Rod) <br /> )vl <br /> REVISED 11/172003 <br /> RCVIJCV �u�ncw.+ <br />