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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> t'OA�Es � (Z STNR ► FAee1a139 SROOg5s9a <br /> OWNER/OPERATOR CHECK if BILUNG ADDRESS❑ <br /> po YgeR7-*-E ► <br /> FACILITY NAME IN -ro 0 Io ) "-:L <br /> SITE ADDRESS s. QAC`( BLVl9' <br /> v <br /> '3 Street Number Direction Sheet Name C Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> S 51- C90-1 ` ` Street Number Stred Na <br /> CITY STATE ZIP <br /> ) <br /> PNONE#1 APN# LAND USE APPLICATION# <br /> ( �, X36 - g <br /> PHONE#2 En. SOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUE OR CHECK if BILLING ADDREss❑ <br /> BUSINESS NAME PHo� <br /> �21 <br /> HOME Or MAI NG ADDRESS FAx# j5 J b <br /> 3 ? 1 1 <br /> CITY / CA STATE <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge [hat 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: DATE:� <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MAN 6R A OTHER AUTHORIZED AGENT[3 <br /> 1fAPPL1CANT 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: I I PAYMENT <br /> COMMENTS: <br /> OCT 11 2022 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE#: 2. 3 DATE: <br /> ASSIGNED TO: �Q .V) ,� EMPLOYEE#: '•-tYS%CJ DATE: 2'z- <br /> Date <br /> ZDate Service Completed L,(if-already completed): SERVICE CODE: I P1 E: 1 <br /> Fee Amount: 15(9 1 <br /> Amount Paid 4 (S—�, I Payment Date 2,�{j L7j <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 'rL -l) `/12, C <br />