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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# S WVI E REQUEST## <br /> Ve,+elZntn-5 JKI otl IUE"I3 <br /> OWNER/OPERATOR CHECK if BILLING ADDRESS <br /> MER1GRJi� /0 IV <br /> FACILITY NAME K JC OC { / <br /> SITE ADDRESS 2 �qe . ,J YM O IN 5�O� <br /> e Number Direction Stme Name Ci h 2i Cotle <br /> HOME or MAILING ADDRESS (if Different from Site Address) <br /> $tree[Number Street Name <br /> CITY STATE ZIP <br /> PHONE#I Exr. APN# LAND USE APPLICATION# <br /> to 6 3 — 795 <br /> PHONE#2 ET. BOS DISTRICT LOCATION CODE <br /> (201 341 - 6 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR N <br /> � 5 A� �' / MA CHECK if BILLING ADDRESS <br /> BUSINESS NAME IK� IL-n d C 5 / � ,5T I / PHONE# — ; Ems' <br /> HOME or MAILING ADDRESS ✓> J (, FAX# — <br /> eb2o Mtru ( ) <br /> CITY Dv//� 1 STATE /r d ZIP q ;�O v <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 FEDE L law <br /> APPLICANT'S SIGNATURE: yz <br /> PROPERTY/BUSINESS OWNERS OPERATOR/MANAGE OTHERAUTHf' /'/� <br /> If APPLICANT is not the BILL/NG PARTY proof of authorization tr ed Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicabl, or operator of the property located at the <br /> above site address, hereby authorize the release of any and all results :al data and/or environmental/site assessment <br /> information t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTML.., soon as it is available and at the same time it is <br /> provided to me or my representative. PAYMENT <br /> TYPE OF SERVICE REQUESTED: CCNLyv RECEIVED <br /> E® <br /> COMMENTS: OCT ) O 2020 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: /'I v'Y ti e S EMPLOYEE M DATE: O <br /> ASSIGNEDTO: O s EMPLOYEE#: DATE: to[ <br /> Date Service Completed (if already completed): SERVICE CODE: pip PA: <br /> Service G 2 <br /> Fee Amount: $Z Amount Paid 41 /S 2 Payment Date <br /> Payment Type Invoice# Check# � Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br /> (�Y�O�-Pto3D� <br />