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' SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 'srAgXAA8 <br /> OWNER/OPERATOR ,t <br /> JOC JO /tl CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS ^ J �_ ��� a <br /> Street Number Olrecllon St at Nama Cit 2I Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 ExT APN# LAND USE APPLICATION# <br /> PHONE#2 En. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR A , I yG`, _ I 1 <br /> Naf�S �/y .I vIG CHECK If BILLING ADDRESS 0 <br /> BUSINESS NAME �� PHONE — Em. <br /> LCY-- CAL HOME or MAILING ADDRESS FAX## <br /> CITY STATE CA- <br /> ZIP <br /> 52 L-1 <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 application d that the work to be rforme ill be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STATE'k EDERAL 1 s. <br /> APPLICANT'S SIGNATURE: �'Y � DATE: I2 ' 7- 012Z4 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> If APPL/CANT is not the BILLING PARTY proof of authorization to sign is required � Tirle <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 a17d Gt.[b�je it is <br /> provided to me or my representative. o IYI <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: DEC 0 7 2021 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE#: 0 DATE: 2' <br /> ASSIGNED TO: n Q EMPLOYEE#: DATE: I e.� I-).I <br /> Date Service Connoted (if already completed): SERVICE CODE: L)� P/E. I CP0 I <br /> Fee Amount: {.F. "(� Amount Paid _ — Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />