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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 FED <br />APPLICANT'S SIGNATURE. <br />PROPERTY / BUSINESS OW <br />-0/ <br />OPERATOR / MA U OTHER AUTHORIZED AGE <br />If APP CANT is not the BILLING PARTY, proof of authorization to sign is required <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property FACILITY ID # SERVICE REQUEST # <br />5000(51 69 <br />__VV___Ni-R-i-ed3ERATOR j <br />CHECK if BILLING ADDRESS 0 <br />FACILITY NAME <br />SITE ADDRESS 40, c5--- <br />Street Number Direction <br />ffn / la k RA <br />Street Name <br />j/igli—rCal sP .' <br />zip Code <br />HOME Or MAILING ADDRESS (If Different from Site Address) <br />Street Number Street Name <br />CITY STATE ZIP <br />, <br />PHONE #1 EXT. <br />(473 26--79 <br />APN # 2oci-oo - 697 <br />LAND USE APPLICATION # <br />PHONE #2 EXT. <br />( ) <br />BOS DISTRICT .1 LOCATION CODE <br />9 9 <br />CONTRACTOR / SERVICE RE UESTOR <br />REQUESTOR <br />CHECK if BILLING ADDRESS r/r 1)2--;-:(7-- <br />BUSINESS NAME PHONE # <br />HOME or MAILING ADDRESS 4i-5-90. 6 1--a_ 17,-- FAX # () <br />'osj- C IT Y ap, / ...‹, STATE(f/ ZIP ps--cz--c-_--_)--, <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 />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 and at the same time it is <br />provided to me or my representative. <br />TYPE OF SERVICE REQUESTED: Sc, I Su ly 4 JO tj / 7- /61 l'e /,,e,,oith 61 .54- 0 c,/),, Jr v <br />COMMENTS: ---) YAIE•A , <br />I C IV <br />11PR 01 1 <br />sAN joA „ <br />1 <br />. 2021 <br />H eNV/ :jA(//: COL," <br />ACCEPTED BY: •"""--- ).---e7 Z., EMPLOYEE #: DATE: (- / 9 f 8 417`1.„7; 4...1. <br />'wtAir <br />ASSIGNED TO: A(.., EMPLOYEE #: DATE: IV i /2 i <br />Date Service Completed (if already completed): SERVICE CODE: ,..).? P / E: <br />Fee Amount: () og2 Amount Paid (803,..-- Payment Date ilif /2.1 <br />Payment Type rft Invoice # Check # t1 00 i Received By: <br />EHD 48-02-025 <br />REVISED 11/17/2003 <br />SR FORM (Golden Rod)