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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> �FA13mm 1 371 SRO m $ 7S49 <br /> OWNER/OPERATORF <br /> TAS KP*ftN �J N GH BR CHECK If BILLING ADDRESS <br /> 2W FACILITY NAME M 0TH E P 1N16l A C w S I h1 L <br /> SITE ADDRESS i 3a 4 E' Ha m m e r L in. Ste 4 5+o c K+o n �S a 1 D <br /> Street Number Direction Street Name City Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 3222 i1Qw ctole L/T9-e <br /> Street Number 1/ Street Name <br /> CITY STATE ZIP <br /> i ur2L�CK R L35 ' � <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (lol) g 12- 5 31-1 + <br /> PHONE#2 / EXT. EMAIL BOS DISTRICT LOCATION CODE <br /> (201 ) 6 <br /> 18 0 60C ry) NiW,-NA �dlar, ry\ <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> 11A4, 9,,�A <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> 8 - 211 <br /> HOME or MAILING ADDRESS FAX# <br /> CITY STATE ZIP EMAIL <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 or activity <br /> will be billed to me or my business as identified on this form. <br /> 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: DATE; <br /> PROPERTY/BUSINESS OWNER PERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <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 above site'. <br /> address, hereby authorize the release of any and all results,geotechnical data and/or environmental/site assessment information to the' <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It Is available and at the same time It Aq� to me or my <br /> representative. F� <br /> TYPE OF SERVICE REQUESTED: C .� 1c)0 el) <br /> RA <br /> COMMENTS: 3'Z S-2'{ Z 7 <br /> JOAQUIN 7 <br /> Cnany 0 QI�nerSh "�rNio°"MENTANn' <br /> EPgRTMENT <br /> ACCEPTED BY: Cn r r u-eS C EMPLOYEE#: DATE: 3-2 1 -a4 <br /> //(� <br /> ASSIGNED TO: I e m a,n EMPLOYEE#: DATE: 3-a - '14 <br /> Date Service Completed (if already completed): SERVICE CODE: PI E: �a <br /> Fee Amount: '1 Amount Pai nt PaymeDate EI-2 <br /> Payment Type UJ Invoice# Check#�J Receiv d By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 03122/23 <br />