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NI e i Z Z, <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 00.21 (-o S�2 0D9`1L402_ <br /> OWNER I OPERATOR <br /> CHECK if BILLING ADDRESS❑ <br /> S h of <br /> FACILITY NAME , <br /> a <br /> SITE ADDRESS g! yam,( 7 ✓Lt r- 1 9 r, 5 1 <br /> 2133-5 Street Number Direction 7V [ Street Name City Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Z 6 F [ C Street Numh V Ok L Street Mame <br /> CITY STATE ZIP <br /> ,fe Cel R5 <br /> PHONE#1 EXT. APN# LAND USS APPLICATION# <br /> ISIa ) 1 vo51 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> t ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> " CHECK If BILLING ADDRESS❑ <br /> BUSINESS NAME PHONE# EXT' <br /> Sen <br /> HOME Or MAILING ADDRESS FAX# <br /> 2 A CJ ( ) <br /> CITY leaSTATE ZIP <br /> L _1 b <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. <br /> APPLICANT'S SIGNATURE: DATE: In f z 7� -'- 1 <br /> PROPERTY/BUSINESS OWNER[I OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <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 <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 /> Pr AN T MENT <br /> TYPE OF SERVICE REQUESTED: Fri`J "�/� l- '` -}j�1. �,�/`� <br /> COMMENTS: " <br /> Nmc�f 4 0,^J OCT 2 7 2021 <br /> SAN JOAQUIN COUNT( <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: v Y EMPLOYEE#: DATE: ' 1-2('01 Z <br /> ASSIGNED TO: Y v EMPLOYEE#: DATE: <br /> Date Service Completed (If already Completed): SERVICE CODE: OV I P/E: 1 V,vZ <br /> Fee Amount: Amount Paid s 4 Payment Date I! � 2W I <br /> Payment Type Invoice# Wck# 1 2)3 g Received ay: <br /> EHD 025 •—] �R M (Golden Rod) <br /> REVISEDSED 11/17/2003 / c <br /> J <br />