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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# ,SERVICE REQUEST# <br /> � sou9�o <br /> OWNER/OPERATOR <br /> I-f /!, Q CHECK If BILLING ADDRESS <br /> FACILITY NAME - yp �-L <br /> SITE ADDRESS <br /> Fot �la sr sTd caKrG� yZ;z <br /> Street Number Direction <br /> HOME or MAILING ADDRESS (If Different from Site Address) G /I_ <br /> Q Street Number C Street l n e `� <br /> CIrY STATE ZIP <br /> PHONE#I EXT. APN# LAND USE APPLICATION It <br /> 2-7) 24d -833 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( 1 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR r�.� <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT <br /> P*7 v 42 ^ 3 - Ss-t? <br /> HOME or MAILING ADDRESS FAX# <br /> I a _eA Gayi c ( ) <br /> CITY t7k <br /> SATE 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 <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, STATE and FEDERAL laws. pp�� / �1 <br /> APPLICANT'S SIGNATURE: h �r ' l DATE: p/ka ! Z O Z <br /> PERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> IfAPPL/CANT 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 <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. P <br /> TYPE OF SERVICE REQUESTED: REQ <br /> COMMENTS; <br /> AUG 10 2021 <br /> �,han�e a� o,�ner`sI�;P SAENVIRONNJOAQUINCOLIN <br /> Ty <br /> ME4� Hl) MENTAL NT <br /> ACCEPTED BY: S EMPLOYEE#: 'I K30 1 DATE:- l D 2/ <br /> ASSIGNED TO: ( r EMPLOYEE#: ]_ DATE: Trio/ <br /> Z1 <br /> Date Service Completed (if already completed): SERVICE CODE: v I P E: <br /> Fee Amount: S'1 V� Amount Paid 12 Payment Date <br /> Payment Type C Invoice# 12 1 8'-'/ I Received By: <br /> EHD 48-02-025 'T L SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />