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P9 0S4 8140 <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # <br />SERVICE REQUEST # <br />Sono-9fp l -Z Li <br />�^LI• , .L /]. <br />nv <br />PHgot <br />/ <br />HOME Or MAILING ADDRESS � 1/fid <br />OWNER I OPERATOR <br />if BILLING ADORE55El <br />l/II �I _ <br />CHECK <br />FACILITY NAME `��, rl4i <br />J/U'I,1�,f/ 11 <br />11 <br />Ni <br />DATE: <br />SITEADDRESS <br />ZStf <br />X <br />, <br />DATE: / Z. <br />S N <br />already completed): <br />."aber <br />IDrectlon <br />� <br />f%L <br />eC tName <br />J <br />Zip Cede <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />7 �� <br />Payment Type <br />Street Number <br />street Name <br />CITY <br />STATE ZIP <br />l; C i <br />PHONE#1 Ev. <br />APN# <br />LAND USE APPLICATION# <br />PHONE #2 Exr. <br />( ) <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR D/ Cglp �y�„ ,/ i i <br />,�yb 1{ `/�--N CHECK if BILLING AGGRESS <br />BUSINESS NAMESN —14 <br />< <br />�^LI• , .L /]. <br />nv <br />PHgot <br />/ <br />HOME Or MAILING ADDRESS � 1/fid <br />FAx# <br />CITY %G STATE /!�- ZIP 0 <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 a FEDERAL laws. <br />APPLICANT'S SIGNATURE: ^�\ y DATE:6'( i 7, L (� <br />PROPERTY/ BUSINESS OWNER❑ OPERATOR/ MANAGER ❑ OTHER AUTnORIZED AGENT❑ <br />I, fAPPLICANT 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 salve time It is <br />provided to me or my representative. DA V RA C Lrr <br />TYPE OF SERVICE REQUESTED: <br />TWA Ve' lk& VIS <br />.e( <br />�-�� <br />COMMENTS: �'„ ^' <br />r1Si1, lndf_ <br />O(> <br />�" <br />li <br />DECU 7 2022 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />// ' <br />ACCEPTED BY: / f <br />v <br />EMPLOYEE #: O O <br />DATE: <br />ASSIGNED TO: f <br />t <br />EMPLOYEE ' 7-x{2 <br />DATE: / Z. <br />Date Service Complet (if <br />already completed): <br />SERVICE CODE:/ 00 I <br />PIE: <br />Fee Amount: <br />J <br />Amount Pa S/ _ f -,7l <br />L#/ C/ <br />Payment Date <br />7 �� <br />Payment Type <br />Invoice # <br />Check <br />Received By: <br />EHD 48-02-025 <br />REVISED 11/1712003 <br />SR FORM (Golden Rod) <br />S <br />