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SAN JOAQUIN COUNTY EwntONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property � ( FACILITY ID# SERVICE REQUEST# I SR0 857-75 OWNER/OPERATOR I \ YI`J1 CNEac x BILLING ADDREss❑ F F u Dlrecaon � 21 l�D 1 TTI NGM: x Oxre tr as roe 1 Street Numbs Cnl�- , C STATE nr)2 P APN# LAND USE APPLICATION# PHHONI(NIE�I#P E". BOS DISTRICT LOCATION CODE ( 1 CONTRACTOR/ SERVICE REQUESTOR REQUESTOR CHECK Ir BIW NG ADDRESS BUSINESS NAME PHONE# Ems' HoNE or MAIuNG ADDRESS FAX# ( 1 CITY STATE LP 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 pptfeati n and that the work to be performed will be done in accordance with all SAN JOAQUIN CouNTY ordinance Codes,Stand TAT FED ews z APPLICANT'S SIGNA DATE: I,J PROPER /BUSINESS OWNS PERATO AGER ❑ OTHER AUTHOR@:D AGENT❑ is not the BiLumG 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. PA TYPE OF SERVICE REQUESTED: s u ECEN Commons: SEP 13 2022 SAN JOAQUIN C OUNTY HENVIRON ME NT ACCEPTED By: T. EMPLOYEE#: 04&7 DATE: 9 13 ;U2 ASSIGNED TO: •1). /I Q EMPLOYEE#: g Q a5 DATE: 9 '3 a s Date Service Completed (H already completed): SERVICE CODE: se PIE: 1 b o a Fee Amount: '915(0. 00 Amount Paid ( Payment Date 3 2z PaymentType Invoice# Check# ` Received By: EHD 48-02-025 SR FORM(Golden Rod) REVISED 11/172003