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0 <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />yea <br />FACILITY ID # <br />BUSINESS NAME 'wA 'I•/ t <br />ERACE REQUE # <br />L I U xef} <br />Ezr' <br />HOME or MAILING ADDRESS <br />FAx # <br />OWNER / OPERATOR <br />CITY <br />CHECK If BILLING ADDRESS <br />MO(Y 1 1'+ <br />ACCEPTED BY:- <br />EMPLOYEE#: <br />r7 <br />FACILITY NAME <br />wear <br />r�. <br />EMPLOYEE#: <br />SITEADDRESS 21$� <br />E. yDSevHii-e Ave–' /i�gN��C0. <br />�IS33G <br />Street Nemlref b <br />Sb INa <br />Zi COAe <br />HOME or MAILING ADDRESS (If Different from Site Address) �jOZ2 <br />f ,-, / <br />oa4t- <br />CT <br />O 2 L <br />street ber <br />a <br />'Op—d- <br />I Name <br />CITY <br />STATA E <br />(, <br />� zip S 6 Z <br />IO C <br />PHONE #1 <br />APN # <br />LAND USE APPLICATION It <br />(2-o 1) 92 3 — 75 ie <br />PHONE#2 EXT. <br />BOS DISTRICT <br />LOCATION CODE <br />(2o`() 277-.3G22- <br />CONTRACTOR / SERVICE REOUESTOR <br />REQUESTOR yvtCCY i J i vl- {' <br />l� <br />yea <br />CHECK if BILUNG ADDRESS <br />BUSINESS NAME 'wA 'I•/ t <br />Nov p.,2022 <br />PNONE# <br />Ezr' <br />HOME or MAILING ADDRESS <br />FAx # <br />11 N /o N1 co, <br />CITY <br />STATE c <br />LP f'1 <br />BILLING ACIINOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized went of same, <br />acknowledge that all site and/or project specific ENVIRONNE'NFAL HEALTH DEPARTMENT hourly charges associated with this project <br />or activity will be billed to me or my business as identified on this form. <br />I also certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN IoAQtrrN <br />COUNTY Ordinance Codes, Standards, STATE and FEDERALIa <br />APPLICANTS SIGNATURE: A`$ DATE: / /— O 7 — Z 2 <br />PROPERTY/ BUSViESs OWNER M OPERATOR/ MANAGER❑ OTHERAUTHORILEDAGENTO <br />IJAPPtrantT is not the BH.LIAG PARTY. proof of authorization to sign is required Till, <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 IoAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTN ENT as soon as it is availabld at the same time it is <br />provided to me or my representative. <br />TYPE OF SERVICE REQUESTED:��`, <br />yea <br />COMMENTS: <br />Nov p.,2022 <br />I <br />11 N /o N1 co, <br />Ett, <br />ACCEPTED BY:- <br />EMPLOYEE#: <br />r7 <br />ASSIGNED TO: <br />r�. <br />EMPLOYEE#: <br />--?C <br />DATE: <br />Date Service Comple (if already completed): SERVICE CODE: ,. PIE: , I � •, <br />Fee Amount: <br />,.-' i; , Amount Paid- - <br />J <br />Payment Date <br />Payment Type <br />I ' ', <br />Invoice # <br />Check #' <br />Received By: <br />EHD 48-02-025 <br />REVISED 11/17!2003 ( SR FORM (Golden Rod) <br />