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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />Tt <br />FACILITY ID # <br />S R�VICE REQU�JE <br />�, 1 ►`O en" <br />DEC <br />BUSINESS N E ,-/ <br />I^tx <br />(S,TT## <br />OWNER / OPERATOR <br />CHECK If BILLING ADDRESS <br />L,ctrr C. 7-A or.7R5o h <br />NEglioRoNMECOONT <br />FAcRRYNAME <br />t <br />w <br />SITE ADDRESS �9' / <br />L1J <br />L,OCI�e Ta <br />``,, <br />rd cT• r�- � <br />( <br />L ' <br />2 <br />9Jrp' d <br />Street Number <br />rection <br />Street Name <br />DATE:I 28 ZZ <br />ZI co� <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />9-155 <br />DATE: <br />` �Qr <br />Street Number <br />" aj�' <br />CITY <br />O <br />C STATE LP 0 <br />PH0NE#1 EXT. <br />APN# <br />LAND USE APPLICATION# <br />12.09 loo► -/a, <br />2T/Z2- <br />Payment Type `- <br />PHONE#2 EXT. <br />1 ) <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />Tt <br />CHECK If BILLING ADDRESS� <br />r <br />�, 1 ►`O en" <br />DEC <br />BUSINESS N E ,-/ <br />I^tx <br />1 , <br />/` 0q_(`I r—,ort <br />28 2022 <br />SqN <br />PHONE# EXT. <br />;.0 339 -`(Bo$ <br />HOME8 r MAILING ADDRESane <br />NEglioRoNMECOONT <br />FAX# <br />w <br />G.n.�ii8 <br />1 ) <br />CITY O i <br />STATE zip <br />Ch <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, STATE and FEDERAL laws <br />APPLICANT'S SIGNATURE: I✓' l DATE: OL <br />PROPERTY/BUSINESS OWNER OP R /MANAGER ❑ OTHER AUTNORILED AGENT 13fAPPLiCANTis not the B/ L [ART proof of authorization to sign is required Titre <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, 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 t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it Is available and at ts^ame time it is <br />lte <br />provided to me or my representative. ) ry <br />TYPE OF SERVICE REQUESTED: 1�54tre- C. <br />c AE� <br />COMMENrs: <br />DEC <br />28 2022 <br />SqN <br />NEglioRoNMECOONT <br />EIV7- <br />IOEPgRT <br />ACCEPTED BY:Sk <br />EMPLOYEE #: <br />DATE:I 28 ZZ <br />ASSIGNED TO: <br />EMPLOYEE M <br />DATE: <br />Date Service Completed (if already completed): <br />SERVICECODE: 0 p l <br />I <br />P 1 E: 2 <br />Fee Amount: <br />— <br />Amount Paid <br />15-6. <br />Payment Date <br />2T/Z2- <br />Payment Type `- <br />Invoice # <br />Check # / 5 7JI <br />Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) (� <br />REVISED 11/17/2003 ���� U I/I J <br />