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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property )� p tJLZ.. CHECK IfBILLING ADDRESS BUSINESS NAME O C 5 Tie- cklAut FACILITY ID # A 0A. J i 51 -.PT SERVICE REQUEST # Mob') o.rv- ( AJ e, ASSIGNED TO: J , r -l.. -FA 00�)25% 1 CITY Sfio�VVi SQMV249!�ID OWNER/OPERATOR /fi�� �� _,kA MOr �e, arK CHECK If BILLING ADDRESS❑ FACILITY NAME jQ I •1 O o6 ovne—A1-C f SITE ADDRESS / O 0,c-• Payment Type Invoice # . I �l v 2e 5 w" t oo q5z l�o Street Number Direction Str¢et Name cityZI Code HOME Or MAILING ADDRESS (If Different from Site Address) t Street Number Street Name CITY STATE ZAP PHONE#1 EXT. APN# LAND USE APPLICATION# (ZOT q J�-0)75 PHONE #2 ( EXT. BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR C -I„ Q 11/1 )� p tJLZ.. CHECK IfBILLING ADDRESS BUSINESS NAME O C 5 Tie- cklAut co PI ec, A 0A. J i 51 -.PT PHONE# EaT' o z- 6s - HOME Or MAILING ADDRESS 3 (� 70 Vr f `j r/ MIN ( AJ e, ASSIGNED TO: J , r -l.. (A%# I CITY Sfio�VVi Date Service Completed (if already completed): STATE zip BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all Site and/Or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly Charges associated With this project Or activity will be billed to me or my business as identified on this form. 1 also certify that I have prepared this applica' and that•„t e-a7Gl to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, Standards, STAT nd FEDER la s. APPLICANT'S SIGNATURE: r DATE: I '�"b PROPERTY/ BUSINESS OWNER16L OPE OR/MANAGER ❑ OTHER AUTHORIZED AGENT 13�j/ wS I L �r/r If APPLICAN IS not the BILLING PARTY, proof of authorization to sign is required Title AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, the owner or operator of the property located at the above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it P prYMENT or my representative. TYPE OF SERVICE REQUESTED: a I Z IlZ-ey nD eA h 14 a C h RECEIVED COMMENTS: ,- -Siv- srp Z"-�Sfial11 �1eu} dro i (n.jzrS 3 T''Ut r,�11 2 mew �0.�J��1iS A 0A. J i 51 -.PT NOV 0 6 2020 SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT ACCEPTED BY: ,'(V1o��J EMPLOYEE #: DATE: 1V ASSIGNED TO: J , r -l.. EMPLOYEE#: DATE: Date Service Completed (if already completed): SERVICE CODE: s23PIE: ?koo'z Fee Amount:, 7J�L..I Amount Paid �— Pa ment Date CC Payment Type Invoice # Check # S Received By: EHD 48-02-025 SR FORM (Golden Rod) 07/17/08