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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # <br />SERVICE REQUEST #OWNER <br />[�L_ <br />1 OPERATOR <br />CHECK If BILLING AUDRE55❑ <br />FACILITY NAMES <br />SITE ADDRESS <br />, <br />Street Number Direction <br />treat Nem <br />Cit <br />- ZIP Code <br />HOME or MAILING ADDRESS (If Different from <br />Site A dress) <br />Street Number <br />Street Name <br />CITY <br />STATE zip <br />PHCNE y1 - ExT. i <br />API # <br />LAND USE APPLICATION # <br />PHC! E#2 ExT- <br />( I <br />BCS DISTRICT <br />LOCATTON CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />IiEOUESTOR <br />Tom/ & jo (e h CHECK If BILLING ADDRESS❑ <br />BUSINESS NAMEExr. <br />Alt°w tSfp rel D 9� s of wa PHONE # <br />K Nf�Cv-rl9gA' <br />HoME or MAILING ADDRESS FAx9 <br />( I <br />CITY STATE zip <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, ST TE -and FEDERAL laws. <br />APPLICANT'S SIGNATURE: / �`r c DATE: <br />PROPERTY I BUSINESS OWNER OPERATOR/MANAGER 0 OTHER AUTHORIZED AGENT 0 tom' im iZ <br />If'APPLIC is not the BILLING PARTY proof of authorization to sign is required Title <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, 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 environm ent <br />information to the SAN JOAQUIN COLIN•rY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available an tYJ <br />t is <br />provided to me or my representative. CEIVEQ <br />TYPE OF SERVICE REQUESTED: <br />COMMENTS: JUN 2 8 2021 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />ACCEPTED BY: L <br />i EMPLOYEE #: O 3 r DATE; <br />ASSIGNED TO: V I EMPLOYEE #: 03I N DATE; <br />Date Service Completed (if alread completed): SERVICE CODE: P ! <br />Fee Amount: Amount ?aid 4k — Payment Date <br />Payment Type ` Invoice # Check # �� s Received By. <br />EHD 48-02-025 SR FORM (Golden Rod <br />REVISED 11/1712003 ) <br />