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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property /Y tQntR, n^ CHECK if BILLING ADDRESS BUSINESS NAMENC, V 1 Gw I FACILITY ID # SERVICE REQUEST # M�lJortald s con. eKG HOME Or MAILING ADDRESS � �2, t CITY F G STATE CA ZIP Ct 3 �y OWNER/ OPERATOR MIA LTO I� D ` Vy JOCL Vt„ / v� CHECK it BILLING ADDRESS -h0 FACILnNAME/ G honot,ld s C4'AVC C J SITE ADDRESS 3 ZZ S. Lely- V- �" s+o G1—'�"D[1 pc IJZD3 I Street Number Direction Street Name ASSIGNED TO: Zip Code HOME Or MAILING ADDRESS (if Different from Site Address) S�OSizt Date Service Completed (if already completed): CICO �w Pi0.G G SERVICE CODE: SZ Number PIE: Street Name 1 CITY Sf Obi K—ipV� Payment Date STATE ZIP (,-A ZOO PHONE #f EMT APN # LAND USE APPLICATION M (Z� X13 - I ZZS Received By: PHONE#2 EXT. BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REOUESTOR REQUESTOR�j - 9eK Gi.rr'Y.lt _ p/29 LGJ /Y tQntR, n^ CHECK if BILLING ADDRESS BUSINESS NAMENC, V 1 Gw I PHONE # EXT. HOME Or MAILING ADDRESS FAx# CITY F G STATE CA ZIP Ct 3 �y BILLING ACKNOWLEDGEMENT: 1, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project Directivity will be billed to me or my business as identified on this form. 1 also certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, Standards, STATE and FEDERAL laws. 6/27/2022 APPLICANT'S SIGNATURE: DATE:_�j n PROPER'il'/ BUSINESS OWNER❑ OPERA RIMA. •i❑ J OTHER AUTHORIZED AGENT I,�' if APPLIC.4w is not the BILLING PARn proof of authorization to sign is required Title AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, the owner or operator of the property located at the above site address, hereby authorize the release of any and all results, geotechnical data and/or environmentaUsite assessment information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It IS available and at the s time It Is provided to me or my representative. q TYPE OF SERVICE REQUESTED: NAC- '--> COMMENTS: O EHD 45-02-025 SR FORM (Golden Rod) REVISED 11/17/2003 �le��t�-�1Ic TINS ,NFA TyoQMCO FN� ARTM�N ACCEPTED BY: /' . EMPLOYEE #: DATE:_�� ASSIGNED TO: EMPLOYEE M DATE: �. �'?--Z2i Date Service Completed (if already completed): SERVICE CODE: SZ PIE: Fee Amoun [� O Amount Paid DD Payment Date (p 2 ZZ Payment Type Invoice # Check # !C� Received By: EHD 45-02-025 SR FORM (Golden Rod) REVISED 11/17/2003