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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT
<br />SERVICE REQUEST
<br />Type of tiusinesg' or Property
<br />,
<br />eil
<br />FACILITY ID # .
<br />CQ00 ,14C
<br />SERVICE REQUEST #
<br />fite .... owNEiv 0 ERATOR
<br />CHECK if
<br />fi C-17
<br />BILLING ADDRESS
<br />FACILI ME 1.
<br />-171$ / 69/ A.),b .--1 -
<br />SITE ADDRESS
<br />5 ki taleetitiumber Direction M(114e0C- - - Str eeV- ame
<br />,S)t-Odehin
<br />City 9rbc 2 p Code
<br />HOME Or MAILING ADADRESS (If Different frizSite Address)
<br />3-V) S---- /4.....S5C.e ej Street Number i
<br />Street Name
<br />CITY ,^ "TE ZIP
<br />PHONE #1 EXT.
<br />( 9(i) :3ii —7;-çe
<br />
<br />APN # LAND USE APPLICATION #
<br />, . EXT.
<br />(21V) 073 --//ç7',
<br />BOS DISTRICT LOCATION CODE
<br />CONTRACTOR / SERVICE REQUESTOR
<br />RECrTOR h,,,,,
<br />Bus NAM ...,
<br />CHECK if BILLING ADDRESS lai
<br />. sic/7 66,T K,Ve PHONE # EXT. ,
<br />HOME Of LVIAILING9,DRESS
<br />i---V,) C 6if 3S tf.e k' I."( ) % Ay/
<br />FAX #
<br />( 1
<br />CITY 25 talt...hir7 STh... ZIP ,---
<br />/
<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 />DATE: APPLICANT'S SIGNATURE:
<br />PROPERTY / BUSINESS OWNER
<br />!--31/4 9.1/463 a
<br />ERATOR / MANAGER 0 OTHER AUTHORIZED AGENT 0
<br />IJAPPLICA 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 andi/di e same time it is
<br />provided to me or my representative.
<br />TYPE OF SERVICE REQUESTED: y, --hct 1-2,7 c c vic, t- —c 6- ,,,-- 'ivto
<br />COMMENTS:
<br />AW j r,_ i 2022
<br />"0
<br />AttIR 0 7
<br />zArchil,,„ , ht,44 ,JiiouNr
<br /> 1 6-847",..rdit '
<br />,
<br />ACCEPTED BY:EMPLOYEE #: DATE: / ,_ ?, 2._
<br />ASSIGNED TO: C., c v -y,,,,L(.....,, EMPLOYEE #: DATE:
<br />Date Service Completed (if already completed): SERVICE CODE: C .2_3 PIE: /(...,0 (
<br />Fee Amount: 2_4 )5-(i? --/ , Amount Paid ,4, LI ,ie Payment Date
<br />Payment Type (41t(1J)) Invoice # Check # 21 011 Received By: av-hr
<br />EHD 48-02-025
<br />REVISED 11/17/2003
<br />SR FORM (Golden Rod)
<br />5144L-12-
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