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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property 'O V (.-c CHECK if BILLING ADDRESS FACILITY ID # SERVICE REQUEST # OWNER I OPERATOR � CHECK if BILLING ADDRESS O FACILITY NAME FAX # CITY L \ ; SITE ADDRESS Street Number DlreL.n Street Name Lo CI"'—Zip Code HOME or MAILING ADDRESS (If Different from Site Address) Street Number Street Name CITY ACCEPTED BY: L Z, STATE ZIP PHONE #'I Ex -r. ( ) DATE: r -71 � APN # a4C 2-0 LAND USE APPLICATION # PHONE #2 ExT• ( ) ' a DATE: 6/9 7 BOS DISTRICT L1 LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR C 'O V (.-c CHECK if BILLING ADDRESS BUSINESS NAME C-0� �c � o� '.�..�r, � . PHONE# ExT• \ �G\ � HOME or MAILING \ADDRESS \ r FAX # CITY L \ ; STATE ZIP BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or project specific ENVIRONMENTAL 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 to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, Standards, STATE and FEDERAL laws. APPLICANT'S SIGNATURE: DATE: PROPERTY/ BUSINESS OWNER PERATOR /MANAGER ❑ OTHER AUTHORIZED AGENT If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required Title AUTHORIZATION TO RELEASE INFORMATION: When applicable, i, 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: VE> f1o�t� �Pc7J'1 f 1ei'.Ll7 �1✓lc�' -o COMMENTS: RECEIVEDCALL (209) 953-7697 FOR INSPECTION. JUN 2 7 2022 48 HOUR NOTICE SAN JOAQUIN COUNTY REQUIRED. ENVIRONMENTAl ACCEPTED BY: L Z, EmPLd#4WTH DEPARTMENT DATE: r -71 � ASSIGNED TO: r� ��• /_ EMPLOYEE #: ' a DATE: 6/9 7 Date Service Completed (if already completed): fJPSW,,4 SERVICE CODE: C) I PIE. L' ,;, 0 d Fee Amount:-2-a Amount Paid `'1�� Payment Date Co 2 2 Payment Type Invoice # eck 0 d$ W� Received By: EHD 48-02-025 V1 REVISED 11/17/2003 %, � U SR FORM (Golden Rod)