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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> �{ S �W$r541 ) <br /> OWNER/ PERAT R <br /> CHECK If BILLING ADDRESS <br /> 7,4 <br /> FACILITY AMEEll e� <br /> _ <br /> SITE D !!�� '^(//�� ' I ,[]� (/ <br /> Street Number Direction Q, Street Name L� v`-�cl @'-1 (F` Afd.6 <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> i <br /> Street Number Street Name <br /> CITY STATE ZIP /; ^ '\ <br /> PHONE#'I ExT• APN# LAND USE APPLICATION# <br /> PHONE#2 W. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE RROII T-O <br /> REQUESTOR <br /> L CHECK If BILLINGADDRESsE] <br /> BUSINESS NAME \ PHONE#) ExT. <br /> HOME Or MAILING ADDRESS FAX# <br /> ( ) <br /> CITY STATE ZIP <br /> BILLING ACKNOWLEDGFAENT: 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 I have prepared this application and that the work to be perfor ed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STATE and FEDERAL h 7 <br /> APPLICANT'S SIGNATURE: DATE: /✓ l// <br /> ROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT <br /> IfAPPL/C.4NT is nor the BtLL7NG PARTr 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 /> PAYMENT <br /> TYPE OF SERVICE REQUESTED: w <br /> COMMENTS: RECEIVED <br /> JUN 15 2022 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> 1C-IIEALT.LJ DEPARTMENT <br /> ACCEPTED BY: EMPLOYEEM p /5 'y2 DATE: <br /> ASSIGNEDTO. EMPLOYEE#: r 2-'-; DATE: /w ✓5 �Z <br /> Date Service Completed (if already completed): SERVICE CODE: / 1' Q �p IE: 1 i0 <br /> Fee Amount: •0 Amount Paid S� Payment Date l(� 2- <br /> L <br /> Payment TypeV G iit Invoice# Che l sZs Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />