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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property . <br />Med Diaeetinelill- R au ei-s <br />FACILITY ID # SERVICE REQUEST # <br />SR00S5q9 a <br />OWNER! OPERATOR Ail _ <br />rreocto (m)ici L.st--- 1.-e 2_ CHECK if BILLING ADDRESS <br />FACILITY NAME /"i...5 wi e 54_0 to vi A/ u l_ri,e_ it t , 7 <br />SITE ADDRESS / 4.9_ 7 <br />Street Number F Direction 1 , es - - -fruori $-1-rtd-- <br />— CU° Street Name <br />Si-0c __I-otrA <br />City <br />c/..,s-z 0 :07 <br />Zip Code <br />HOME Or MAILING ADDRESS (If Different from Site Address) <br />52-, 5 Rro Me,Scs WC( Street Number <br />i s- moyc, <br />Street Name <br />CITY STATE <br />GCL <br />ZIP <br />PHONE #1 EXT. <br />(ZOCi) g.‘/Cf —0 7 3 ? <br />APN # LAND USE APPLICATION # <br />PHONE #2 EXT. <br />( ) <br />BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR CHECK if BILLING ADDRESS <br />BUSINESS NAME PHONE # <br />( ) <br />EXT. <br />HOME Or MAILING ADDRESS FAx # <br />( ) <br />CITY STATE ZIP <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 erformed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards, STATE and FEDER aws. <br />APPLICANT'S SIGNATURE: <br />PROPERTY / BUSINESS OWNER 0 OPERATOR / MANAGER 0 OTHER ORIZED AGENT 0 <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, geoteclmical data and/or environmental/site assessment <br />information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available aiA at the same time it is <br />provided to me or my representative. A Ynell <br />- ... <br />Ert TYPE OF SERVICE REQUESTED: "ECEIV <br />la , <br />COMMENTS: NOV 0 4 2022 <br />SAN jOAQUiN <br />;./ ENVIRONJU C°UNTY <br />" '6ALTH bep'"eNTAL <br />ARTMENT <br />ACCEPTED BY: EMPLOYEE #: c, 2_1 3 DATE: i ( / yl,-, , <br />/ <br />s <br />......) C- TO: ASSIGNED EMPLOYEE #: <br />q 7—'5- <br />DATE' <br />Date Service Completed (if already completed): SERVICE CODE: ( f <br />Fee Amount: bk ( 0 <br />Amount / <br />P <br />Payment Date /1742_2___ <br />Payment Type _).,_ Invoice # Check # /3121 Received Byd/yr— <br />DATE: //3/z2- <br />EHD 48-02-025 <br /> SR FORM (Golden Rod) <br />REVISED 11/17/2003