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' SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MJ' (�Q� SERVICE REQUEST Type of Business or Property FACILITY ID# SERVICE REQUEST# Ca}cr� / ooD v&-HooTL FS�Z OWNER/OPERATOR Marie v Jcl CHECK If BILLING ADDRESSO FACIU NAME 6n.Rt+T- ?;K %- LDm6k-' (J-e \- 0\ \S) ' 00 2 2 SITE ADDRESS�. (1,t �w -3 `q 'L; Streot Number Dlre tion V� �Svee Nama cit —`Zip cood. HOME or MAILING ADDRESS (If Different from Site Address) /r�,72 C""�.(T Pwk-- C L street Number Street Name CITY 1 (yyyt�Q STATE zl^Pc4t�� PHONE#1 1 T1 ECT. APN# LAND UUt SE APPLICATION It ./ (1{041 � 2-"-41 PHONE#2 ExT BOS DISTRICT LOCATION CODE CONTRACTOR/ SERVICE REQUESTOR REQUESTOR MWEso 150z"Pla CHECK if BILLING ADDRESS BUSINESS NAME HT yt__��-yEC I MI PX E# T• l�tJ r,A} 7 �P� L1•C HO or MAILING ADDRESS FAX# bill 32 CO-SC-CAT ►ftw ciRr I ( ) CmLf"ft? ST ZIP G/ 1`2 BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all Site and/or project Specific ENVtRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as identified on this form. I also certify that I have prepared this application and that the work t0 be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes,Standards,STATE and FEDERAL laws. � APPLICANT'S SIGNATURE: y�� DATE: VI'In V/20 n- / PROPERTY/BUSTNESSOWNERW OPERATOR/MANAGER ❑ OTNER AUTHORIZED AGENT[3 IfAPPLzcANT is not the BILLLVG PARTP proof of authorization to sign is required Title AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, the owner or operator of the property located at the above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. TYPE OF SERVICE REQUESTED: PAY MENT COMMENTS: JAN 1 1 2022 SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT ACCEPTED BY: EMPLOYEE#: DATE: —` ASSIGNED TO: tt1VVV"`�� EMPLOYEE#: DATE: Date Service Completed (if already completed): SERVICE CODE: PIE: I i/1 O Z Fee Amount: +1 O)2-- Amount Paid /S Z — Payment Date It 1D Z L Payment Type Visa- Invoice# Cp,16it# ( 3� Z 3SG 3 Received By: )+/7 END 48-02-025 SR FORM(Golden Rod) REVISED 11/17/2003