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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Properly <br />5'�qurA fi TeQ mom <br />FACILITY ID # <br />�Robo� (v <br />SERVICE REQUEST # <br />�1200Ap 958 <br />OWNER/OPERATOR E��ZA� Uredo <br />CHECKif BILLINGADDRESS <br />FACILITY NAME M2Qj 1 L•�1�{e� �/j,A <br />Fes# <br />SITE ADDRESS '✓�� <br />Street Number <br />N --f <br />tion <br />W' <br />L/t/�yy1 <br />T\1V\1G„ <br />a e <br />I.Y Vt� <br />Lodi <br />City <br />/} <br />`-'1520 <br />Zip Code <br />HOME or MAILING ; DRESS (if Different from Site Address) <br />Street Number <br />O Uno <br />Inst <br />CITY <br />STATEC LP L C•1Joq <br />Vt ✓� <br />PHONE#1 E". <br />ell) 452-,: ('6W <br />APN# <br />EMPLOYEE#: <br />V <br />LAND USE APPLICATION# <br />PHON ) En, <br />I U5-5156 <br />SERVICE CODE: b <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REOUESTOR <br />REQUESTOR i-mb 'jam �O��0 <br />CHECK If BILLING ADDRESS <br />BUSINESS NAME n L�J•-I�Int/t Yr�/1 �lyl <br />V 1 1 , <br />oo <br />ED <br />EXT. <br />L—+'✓ V/ <br />il1/1 <br />HOME or MAILING ADORES'$ _t a1 0cXr <br />yu <br />Fes# <br />CITY w <br />STATE Til LP II 2 <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, Standards, S ATE and FE ERAL laws. <br />APPLICANT'S SIGNATURE: qbA DATE: 1'21012-1 <br />PROPERTY/BUSINESS OWNER OPE(IITOR/MANAGER ❑ OTHER AUTHORIZED AGENT E3 <br />IjAPPLICANT is not the BILLING PAR proof of authorization to sign is required Titre <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. In <br />TYPE OF SERVICE REQUESTED: <br />'—H Y' • r <br />COMMENTS: <br />ED <br />OEC 2 0 2022 <br />SAN <br />HEALAQUIN <br />TH p NMENTA NTy <br />ACCEPTED BY: - <br />EMPLOYEE#: <br />DATE: 12 <br />L <br />ASSIGNED TO: <' <br />EMPLOYEE#: <br />V <br />DATE: v 2 <br />Date Service Completed (k already completed): <br />SERVICE CODE: b <br />PI 2— <br />Fee Amount: % <br />Amount Pal <br />` O� <br />Payment Date 20 2Z <br />Payment Type )50� Invoice # <br />Check # 's S <br />Receive By: <br />EHD 43-02-025 <br />REVISED 11/17/2003 <br />�� Ilvoo3l <br />SR FORM (Golden Rod) <br />