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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID III <br /> SERVICE REQUEST# <br /> Cow6_1I'6-RT STaee- SQOOVi 52�\D <br /> OWNER/OPERATOR AMTIT �r��' <br /> J l (4 CHECK If BILLING ADDRE55o <br /> FACILITY NAME PR- 1 M E M&eKET y'� d <br /> SITE ADDRESS., �O.SE/�IIT� /T!/C 04#1q TC CA 5.33.0 <br /> 5 /� SVeer Number Direction Street Name Cit ZipCode <br /> HOMEorMAILING ADDRESS (If Different from Site Address) <br /> I T6-SoRip /oStreet Number Street Name <br /> CITY MANL C E /'�C ^ STATE C ZIP s33 �- <br /> PHONE#t G EXT. APN# LAND USE APPLICATION It <br /> (Slo) 3614 -2422 I 219-400 -ozo <br /> PHI ;209 _ gL EXT BOS DISTRICT LOCATION CODE <br /> vl UX CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> HOME or MAILING ADDRESS FAx# <br /> CITY STATE 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 1 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. a� <br /> APPLICANT'S SIGNATURE: /�lt! DATE: ����3�i�OZ L <br /> PROPERTY/BUSINESS OWNERO OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> IJ'APPLICANT is not the BILLwc PARTY proof of authorizution 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 environ ntal/site assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available antime it is <br /> provided to me or my representative. RR TT <br /> TYPE OF SERVICE REQUESTED: 40A mc(k <br /> COMMENTS: 2021 <br /> S Ey&-pit UIN COUN <br /> hQIMpN <br /> '."tfMFllq' <br /> ACCEPTED BY: EMPLOYEE#: DATE: V 7 ZI <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: P I E: (� <br /> Fee Amount: 'A"J Amount Paid Payment Date 2 3 <br /> Payment Type Invoice# Check# I Received By <br /> fuA <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11117/2003 �O Z'D i <br />