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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />BUSINESS NAME <br />FACILITY ID # <br />�oboas�l c� <br />HOME Or MAILING ADDRESS <br />SERVICE REQUEST # <br />S 0 12 <br />OWNER/OPERA OR <br />/J <br />l% <br />CHECK It BILLING ADDRESS� <br />FACILITY NAME + , _ % / / <br />f J' <br />l/ <br />l• <br />YY1/.1/�u' ✓ <br />I—f! <br />/" <br />SITE ADDRESS <br />Street Number <br />I Direction <br />I've <br />Street Name <br />�^./�, ,, I <br />city <br />-��-7 <br />Zia Cod. <br />HOME or MAILING ADDRESS (If Different from Site Address) - <br />,2()-%, r–i rQi L(% o tZ AV -e Street Number <br />Street Name <br />CITYSTATE <br />Zip <br />415 <br />PHONE#1 EM• <br />(�vk) a�S -39x3 <br />APN # <br />LAND USE APPLICATION # <br />PHONE#2T• <br />l ) <br />DATE: <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUEST_OR �� /�/ rI ` r <br />S t r (/.�{ La- bale CHECK if BILLING ADDRESS <br />BUSINESS NAME <br />PHONE# EXT. <br />HOME Or MAILING ADDRESS <br />FAX# <br />CITY STATE 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: <br />DATE: <br />PROPERTY / BUSINESS OWNER❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br />If APPLICANT is not the BILLING PARTY 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 the or my representative. pAVAw _ <br />TYPE OF SERVICE REQUESTED: COI `sUiLY 4 �J� <br />.�j� <br />42„n <br />`C'Vltiv/ <br />COMMENTS: <br />13 <br />2022 <br />THNE pRCCUa <br />TMENT <br />% I n /` <br />ACCEPTED BY: Y^(� ��L/',(_ C2 /7 <br />'7C— <br />L� <br />EMPLOYEE L�•'� <br />DATE: <br />ASSIGNED TO; l G,./ C <br />�i <br />EMPLOYEE #: LQ��/ <br />DATE: <br />Date Service Competed (if already completed): <br />SERVICE CODE: <br />PIE: 60 <br />Fee Amount:`S� <br />Amount Paid�5'� <br />Payment Date <br />/`/3 <br />Payment Type (ilZepl-7— <br />Invoice# <br />Check# lC 15 OZ <br />Received By: <br />EHD 48-02-025 C.� �%/2 /n�� �� �+/' 53 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />