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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID # SERVICE REQUEST # <br /> OWNER I OPERATOR <br /> FeA e;lK 6q r0 CHECK if BILLING ADDRESS <br /> FACILITY NAME PM pX r^ � � <br /> SITE ADDRESS <br /> 1'( (/t ri vL rt/�V/ q S 3 77 <br /> l!� �% Street Number Direction 1 yv�"` Street Name City Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE #1 Exr. APN # LAND USE APPLICATION # <br /> PHONE #2 ExT• BOS DISTRICT LOCATION CODE <br /> ( <br /> CONTRACTOR / SERVICE REQUESTOR <br /> R50UESTOR � CHECK if BILLING ADDRESS ® <br /> BUSINESS NAME , PHONE # ' - ZI ExT <br /> ? t+Ak <br /> 1 Y✓vv,rM• • . <br /> HOME or MAILING ADDRESS /y O yam , �, „ Q FAX # <br /> CITY <br /> t STATE 2 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 /> 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 a d FEDERAL IaWS . / <br /> APPLICANT'S SIGNATURE : DATEEF ��"2/ <br /> PROPERTY I BUSINESS OWNER 13OPERATOR / MANAGER 13 OTHER AUTHORIZED AGENT 6�I LOr. 4 nCAft•, <br /> If APPLICANT 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 /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as Soon as it is available and at the same time it is provided t0 me Or <br /> my representative . A ' <br /> TYPE OF SERVICE REQUESTED : ► Y T <br /> COMMENTS: � n VtD <br /> /fes' AUG 19 2021 <br /> SAN JOAQUI <br /> HEALTH pE ER cot <br /> TY <br /> ACCEPTED BY: EMPLOYEE #: DATE: (� <br /> ASSIGNED TO : Y^ J ` `-J EMPLOYEE #: DATE : ! J <br /> Date Service Completed (if already completed) : SERVICE CODE: elp 42 /.JiC, P / E: 2Al i <br /> 7v, <br /> Fee Amount : L /900 Amount Paid (� v Payment Date _[ S <br /> Payment Type1 -r Invoice # Check # Receiv d By : <br /> EHD 48-02-025 SR FORM (Golden Rod) <br /> 07/17/08 <br />