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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />CHECK If BILLING ADDRESS� <br />05 <br />J e v t 61 <br />FACILITY ID # <br />SERVICE REQUEST # <br />SEP Lrt 8 2o22 <br />PHONE# En. <br />'%ci-1 <br />`oLI Er 6YV,i q 1 4 S <br />SAN JOAQUIN COUNTY <br />Sic oog5l�3�0 <br />OWNER/OPERA OR <br />• <br />CHECK If BILLING ADDRESS <br />V e , ^ <br />`' <br />Y <br />( ) <br />FACILITY NAME +'f 6 <br />0 <br />DATE: 9 Q <br />ASSIGNED TO: 1 - <br />EMPLOYEE #: <br />DATE: I?, ^ � . <br />�1 <br />SITE ADDRESS <br />t 1 <br />SERVICE CODE: <br />523 <br />, /t At,n s-4 <br />` <br />I —CrvH <br />Fee Amount: 4 <br />I d 1 D Street Number <br />DIIre'eetion <br />Payment Date <br />Iv <br />Street Name <br />Chsekl# It (3 �; `k / y Z <br />ZI Cotle <br />HOME or MAILINGS DRESS (IF Differfrit from Site Address) <br /><+ � A' +� C..4 <br />J <br />L J 7 S <br />Street Number <br />Street Name <br />Crty <br />CRATE zIP� <br />{J <br />aX.L <br />PHOON�E##1 Ear. <br />APN # <br />LAND USE APPLICATION # <br />( �." 1) 2 L L1 19 <br />1 <br />PHONE #2 Exr. <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRXCTOR / SERVICE REQUESTOR <br />REQUESTOR <br />C <br />CHECK If BILLING ADDRESS� <br />05 <br />J e v t 61 <br />COMMENTS: <br />BUSINESS NAME /� I <br />SEP Lrt 8 2o22 <br />PHONE# En. <br />'%ci-1 <br />`oLI Er 6YV,i q 1 4 S <br />SAN JOAQUIN COUNTY <br />e1 8� <br />HOME or ld <br />I- <br />ENVIRONMENTAL <br />FAX# <br />/t/,NGnr�ADDRESS <br />/b L 4 .Y ✓l0./ �1 S-� <br />HEALTH DEPARTMENT <br />( ) <br />CITY M QH Lp ��„ <br />STATE /I ZIP <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 and that the work to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards, STATE and FEDERAL laws. <br />APPLICANT'S SIGNATURE: //jJ / DATE: 9�2d/2 2 <br />PROPERTY / BUSINESS OWNER❑ OPERhTOIt / N .AN.AGER ED OTHER AUTHORIZED AGENT ❑ <br />If APPLICANT is not the WING PAkTY, 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. PAYMENT <br />TYPE OF SERVICE REQUESTED: <br />CEIVED <br />COMMENTS: <br />SEP Lrt 8 2o22 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />ACCEPTED BY:V. <br />GI <br />e r a Z GI <br />EMPLOYEE M <br />DATE: 9 Q <br />ASSIGNED TO: 1 - <br />EMPLOYEE #: <br />DATE: I?, ^ � . <br />�1 <br />Date Service Completed (if already mpieted): <br />SERVICE CODE: <br />523 <br />PIE: <br />/L0O r <br />Fee Amount: 4 <br />Amount Paid a1 <br />Payment Date <br />A' yU2-2- <br />LPayment <br />Payment Type V 15 A Invoice # <br />Chsekl# It (3 �; `k / y Z <br />I Received By: <br />EHD 4M2-025 SR FORM (Golden Rod) <br />REVISED 1 V17/2003 <br />