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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> FAN a 3559 SROOV(01C01 <br /> OWNER I OPERATOR /y� <br /> A 3 11` ( CHECK If BILLING ADDRESS <br /> VATFACILITY NAMELl I I r� <br /> SITE ADDRESS 0M�-�-� AI—E MAN TCC A33-7. <br /> ( Z Street Number I Dlrectlon "" Street Nama city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 ET. APN# LAND USE APPLICATION# <br /> (209 ) 923 - 179 <br /> PHONE#2 Er. BOS DISTRICT LOCATION CODE <br /> ( l <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR / C <br /> �/t /� n 1 �G CHECK If BILLING ADDRESS <br /> BUSINESS NAME / -I Yr�V f( rV h L PHONE# Ems' <br /> L tAU D C ! 7 <br /> HOME Or MAILING ADDRES FAX# <br /> 1 z u, sT yvSE/M/ TE P VF_ ( l <br /> CITY AN �E f A STATE L ZIP <br /> BILLING ACKNOWLEDGEMENT: 1, 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: Ua nus ll i(FI N P� • DATE: 1 Z/Z U/Z U Z 2 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER 13 OTHER AUTHORizFDAGEN'r❑ GL)S/fl// Si; OUNCJZ <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 /> TYPE OF SERVICE REQUESTED: C O U I T <br /> COMMENTS: <br /> DEC 2 0 2022 <br /> SAN JOAQUIN COUNTY <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: S kA���0 a I W„ Q EMPLOYEE#: /i ,� =DATE: <br /> ASSIGNED TO: G h a4-,17- U rL,✓✓Ww��EEMPLOYEE M 27`T92 DATE: I a -00-as <br /> Date Service Completed (if already Completed): SERVICE CODE: O� ' P/E: Q <br /> Fee Amount: 15 Amount Paid �1 _ Payment Date ( -2f12, 2 2— <br /> Payment <br /> Payment Type V Invoice# jCheCk#l 5 (.l 611 Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />