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Title <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property FACILITY ID # SERVICE REQUEST # <br />GA901S 6/00 <br />OWNER/OPERATOR c <br />I Op .) CIV/0 <br />1 <br />RI ( k el 0. 1Y! L_ L( J <br />CHECK if BILLING ADDRESS <br />FACILITY NAME <br /> ?12o A/14 <br /> ADDRESS AI re iy <br />.5-DD Street Number Direction <br />.5-rb cr—r-ori <br />City 2-ir <br />Zip Code <br />0-71 ceK7-DAt RD <br />Street Name <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />I'" o. /3().- 657 Street Number Street Name <br />CITY STATE il ZIP <br />PHONE #1 EXT. APN # LAND USE APPLICATION # <br />PHONE #2 EXT. <br />(76 '7) 06-- 1)42- <br />BOS DISTRICT 9 LOCATION CODE <br />q Ci <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />4-4A/C /-iq 6- --7t i 17e > CHECK if BILLING ADDRESS <br />BUSINESS NAME <br />in 0 fe-413 A 7212t...)61 C -e. PH , <br />(44 51/ 4P - Oz /Z 4' <br />EXT. <br />HOME or MAILING ADDRESS FAX # <br />(74.-/-3 ) <br />Crry 1--Ait/00‘i STATE 0.4.4 Z I P <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 />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, STAJ and FEDERAL laws. <br />APPLICANT'S SIGNATURE: <br />PROPERTY / BUSINESS OWNER0 OPERATOR / MANAGER . OTHER AUTHORIZED AGENT 0 <br />If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required <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 fEntaghlfTD: (.... 0 d i ; I-6,10 i 1 1}7 eilici tJ :tf ocke t o f re cThi ic; 5.: 4 r R , , , , ; e ,, j <br />commENTRECEIVED <br />JUN 2 4 2021 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />ACCEPTED BY: 2.----/---- .....7•••7- EMPLOYEE #: DATE: L/4 ) <br />ASSIGNED TO: pei .5 EMPLOYEE #: DATE:( 2/) Lik i <br />Date Service Completed (if already completed): SERVICE CODE: c c) 3 <br />Payment Date g2,24 <br />Received <br />PIE: okoc7( <br />Fee Amount: 4 (.., 0? Amount Pak/460X 0 D <br />Payment Type Invoice # Check # 0 2y- By:zity)- <br />DATE: <br />EHD 48-02-025 <br />REVISED 11/17/2003 <br />SR FORM (Golden Rod)