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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />CONTRACTOR/ SERVICE <br />•' <br />FACILITY ID # <br />SERVICE REQUEST # <br />bv <br />CHECK If BILLING ADDRESS <br />NOV 0 6 2020 <br />omrL5 8 ` <br />5(ZCjS2SE <br />,� <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />_ <br />V1 <br />k"J AXILS u� 5 <br />BUSINESS NAME C <br />(` <br />t <br />j <br />Jl <br />OWNER I OPERATOR <br />(r'1 epi <br />�1 <br />CHECK if BILLING ADDRESS E] <br />ill Ou) <br />FACILITY NAME <br />06l I^+ <br />t <br />� �� i O�a� <br />DATE: <br />SITE ADDRESS r O O <br />L727 <br />\ A� i� C <br />�) <br />�- (ay�fi <br />5 +0(,V, } 00 <br />g5Zto <br />Street Number <br />Direction <br />Street Name <br />HOME or MAILING ADDRESS <br />Ci <br />Zi Code <br />Check # <br />S <br />Received By: <br />FAX # <br />HOME Or MAILING ADDRESS (If Different from Site Address) <br />Street Number <br />Street Name <br />CITY <br />STATE <br />ZIP <br />PHONE #1 <br />EXT. <br />APN # <br />LAND USE APPLICATION <br /># <br />(�y) <br />PHONE #2 <br />( ) <br />EXT. <br />BOS DISTRICT <br />LOCATION CODE <br />REQUESTOR <br />REQUESTOR / <br />•' <br />1� <br />v <br />COMMENTS: <br />- V-�r <br />CHECK If BILLING ADDRESS <br />NOV 0 6 2020 <br />e vr� <br />� <br />,� <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />_ <br />V1 <br />k"J AXILS u� 5 <br />BUSINESS NAME C <br />(` <br />t <br />j <br />Jl <br />DATE: II , I / <br />n . 2� <br />V <br />P �0©E# <br />ExT. S <br />' <br />l <br />EMPLOYEE #: <br />DATE: <br />Date Service Completed (if already completed): <br />L727 <br />P 1 E: 2 X02 <br />Fee Amount:, 7J�� , 00 <br />Amount Paid <br />Payment Date <br />Payment Type <br />HOME or MAILING ADDRESS <br /># <br />Check # <br />S <br />Received By: <br />FAX # <br />CITY <br />STATE ` <br />ZIP <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 <br />activity will be billed to me or my business as identified on this form. <br />I also certify that I have prepared this appli <br />COUNTY Ordinance Codes, Standards, STATI <br />to be performed will be done in accordance with all SAN JOAQUIN <br />APPLICANT'S SIGNATURE: ,Z� <br />PROPERTY/ BUSINESS OWNER p61� OPER OMANAGOTHER AUTHORIZED AGENT El rJ,�e"r I ✓ Z1/t <br />If, 4PPLICAN 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 <br />site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information <br />to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It Is available and at the same time it � flpfOVtl�'ENldded to _me Or <br />my reDresentative. %��T <br />TYPE OF SERVICE REQUESTED: RECEIVED <br />EHD 48-02-025 SR FORM (Golden Rod) <br />07/17/08 <br />COMMENTS: <br />- V-�r <br />NOV 0 6 2020 <br />e vr� <br />Cux)s`!s3 <br />,� <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />_ <br />V1 <br />k"J AXILS u� 5 <br />HEALTH DEPARTMENT <br />ACCEPTED BY: KCJI , <br />EMPLOYEE #: <br />DATE: II , I / <br />n . 2� <br />V <br />ASSIGNED TO: J �e <br />EMPLOYEE #: <br />DATE: <br />Date Service Completed (if already completed): <br />SERVICE CODE: Gj 2 2 <br />P 1 E: 2 X02 <br />Fee Amount:, 7J�� , 00 <br />Amount Paid <br />Payment Date <br />Payment Type <br />Invoice <br /># <br />Check # <br />S <br />Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />07/17/08 <br />