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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # <br />�(J 'CJ <br />SERVICE REQU[ESST # <br />BUSINESS NAME <br />�, � <br />PHONE# Ea' <br />Z0q) -7790 <br />HOME or MAILING ADDRESS <br />OWNER I OPERATOR <br />( \137V' /(/i <br />CHECK If BILLING ADDRESS <br />\A� Y 0 <br />( ) <br />CITY C <br />FACILITY NAME <br />EMPLOYEE#: <br />SITE ADDRESS C]U 6- <br />'J <br />I <br />�yar_I ln� j • a' <br />o , (A. <br />�'�F-„��l _ <br />v` 1 V 7(1 �'1 <br />Fee Amount: l�Z _ <br />C6 -20Y <br />_' <br />Street Number <br />Direction <br />StreVetvNamel� <br />Payment Type <br />CI <br />ZI Codve <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />5 • tNr Street Number <br />Street Name <br />CITY <br />OGkrf� <br />STATE ZIP <br />rAF <br />PHONE #1 Eu. <br />APN # <br />AND USE APPLICATION # <br />(2111) _5-1 7 v <br />PHONE #2 Em <br />( ) <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />CHECK If BILLING ADDRESS <br />�(J 'CJ <br />COMMENTS: � � <br />BUSINESS NAME <br />�, � <br />PHONE# Ea' <br />Z0q) -7790 <br />HOME or MAILING ADDRESS <br />FAX # <br />r�2r <br />EMPLOYEE <br />( ) <br />CITY C <br />STATE ZIP (a� � •� <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, ST T and FEDERAL laws. // <br />APPLICANT'S SIGNATURE: 'ATE: l G (ZOZ <br />PROPERTY / BUSINESS OWNER❑ P • r TOR /MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br />IfAPPLiCANT 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. DAVMI=NIT <br />TYPE OF SERVICE REQUESTED: <br />�j C WvtS�A.r�^ <br />RECEIVED <br />COMMENTS: � � <br />D <br />�, � <br />NOV 19 2021 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />ACCEPTED BY: <br />EMPLOYEE <br />DATE: <br />/ OC <br />ASSIGNED TO: <br />J <br />EMPLOYEE#: <br />DATE: <br />Date Service Completed (if already completed): <br />SERVICE CODE: O <br />1 E: <br />Fee Amount: l�Z _ <br />Amount Paid Z _. <br />Payment Date <br />l.( / I <br />Payment Type <br />Invoice # <br />CJ <br />ReceiveB:S y <br />EHD 48-02-025/t �o ����� SR FORM (Golden Rod) <br />REVISED 11/17/2003 Y <br />