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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALPil DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID # :SERVICE REQUEST # <br /> OWNER I OPERATOR CHECK If BILLING ADDRESS ❑ <br /> N ' Qm libnM (Av- <br /> FACILITY NAME <br /> &nnsrxi <br /> srronEADDREss a�1 N , mcmri Sk • Ntcnnkecc \ 853310 <br /> Straet Number Direction Street Name Cf ' ZI Coae <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> 1 `-r • Street Number Street time <br /> C STATEZI <br /> - 1 ' ^ , P <br /> JJ <br /> PHONE #I Ev, APN # LAND USE APPLICATION t1 <br /> ate' ) 0� - � 21y <br /> PHONE #2 Elcr, BOS DISTRICT 7 LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR13 <br /> ( ` ( �� < \� CHECK if BILLING ADDRESS <br /> BUSINESS NAME V 1(. PHONE # Ev' <br /> vorMU ( �E <br /> HOME Or MAILING ADDRESS FAx # <br /> VE ( ) <br /> CITY ��� In STATE ZIP CA <br /> Cj .bl) 60 <br /> MILLING ACKNOWLEllGEMT:NT: 1, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project specific ENVIRONnu:N'rAL IIuAuiII DLPARTnv:NI 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 1 have prepared this application and that die work to be performed will be done in accordance with all SAN JOAQUIN <br /> CotrNTY Ordinance Codes, ,Slandardv, S"TAa'L• and r:DHRAI. laws. <br /> APPLICANT'S SIGNATURE: 1 \\ pA'C-,,>,,�� <br /> PROPLICI'Y / ItuswEss OWNER ❑ OPLRATwt / MANAGER 13Oruuat AuaaiORize0AG1:Nrjt Q 'w\0\ <br /> /fdrrclC,lxr IS 1101 theBy.i.w(y PART3'. proof ofauthorizarion losign is required UI <br /> AUTHORIZATION TO RELEASE INFORMATION : When applicable, 1, the owner or operator of the property located at die <br /> above site address, hereby authorize die release of any and all results, geotechnical data and/or environnlentaLfsite assessment <br /> h ilunionlion t0 (lie SAN JOAQUIN COUNTY 1 ',14VIRONMEN'I'AL I IIiAl:rlI DHPAKI'MHNias 50011 as it is available and at the SaIlle 01110 it i5 <br /> provided to me or my representative, <br /> TYPE OF SERVICE REQUESTED: C 01.13 LI L rh r) 0 ),I PAX <br /> ENT <br /> COMMENTS: RFC <br /> MAY 2 0 2021 <br /> JOPOUIN COUNTY <br /> ftONMEN <br /> TA <br /> EHFALTII OEPAftIMENt <br /> ACCEPTED BY: I N 011 EMPLOYEE #: q 3 G DATE; $ <br /> ASSIGNED TO: 5 1 Nt &14 EMPLOYEE #: 01 $ 3L DATE' <br /> 3ENvlcCODE: PIE: I 0 3Data Service Completed (if elroady completed) : OI <br /> Fee Amount: 6 15 Amount Paid 41S $ Payment Data 61.701a1 <br /> Payment Type C c�pL� Invoice # tN e/ltc/# Z SJ 50 � � i � Received By : <br /> EHD 48-02.025 / _ // 2 � G (� SR FORM (Golden Rad) <br /> REVISED 11117I2OD3 <br />