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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Ty a of Business or Property <br />YYT 14p�Cto <br />FACILITY ID # <br />SERVICE REQUEST # <br />�DOI4 ArucK <br />PHONE# Ex . <br />263 (i <br />HOME or MAILING ADDRESS <br />IsR00959 a 11 <br />FAX# <br />CITY <br />OWNER I OPERATOR <br />STATE ZIP <br />CHECK If BILLING ADD SS <br />FACILITY NAME <br />,At <br />/I ] r A I M O 4 <br />�1 r [,t <br />SITE ADDRESS 6 20 <br />l7 <br />S S a( /GCA vo e' 14 0 S -\\\ <br />i 1 ) <br />J <br />I (X.t I 95 � de <br />Street Number <br />Direc ion Street Name <br />Ci ZipCade <br />HOME or MAILING ADDRESS (If Different from Site Address) 55I? <br />Y' 1/ a )D'r —l1 <br />Date Service Completed (if already completed): <br />e�Number <br />` Street Name <br />CITY <br />I O I <br />Ct <br />oo <br />�E ZIP "i I 'D <br />E#1 <br />PH,N� <br />Ezr, <br />APN # <br />Check # <br />LAND USE APPLICATION # <br />(/OtWf4)gio Ogg <br />PHONE#2 <br />ExT' <br />BOS DISTRICT <br />LOCATION CODE <br />(a) 63 535-9- <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />Or <br />YYT 14p�Cto <br />CHECK if BILLING ADDRESS <br />BUSINESS NAME <br />EL <br />0A/ I A MU <br />PHONE# Ex . <br />263 (i <br />HOME or MAILING ADDRESS <br />FAX# <br />CITY <br />STATE ZIP <br />BILLING ACKNOWLEDGEMENT: 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 />of 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, ST TE and F vs: <br />OZLPRAPPLICANT'S SIGNATURE: DATE: 1Ozl 00 2022- <br />PROPERTY/ <br />OPERTY/ BUSINESS OWNER 13 PERATOR/MANAGER Q OTHER AUTHORIZED AGENT❑ <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 ate time it is <br />provided to me or my representative. ns ,I <br />TYPE OF SERVICE REQUESTED: 'PI h e cl: <br />v��VF <br />COMMENTS: <br />Z 0 �rr� <br />Tye <br />fN�CUtNIY <br />60' <br />ACCEPTED BY: <br />r rue <br />EMPLOYEE #: <br />DATE: (V aO IQ <br />!0 <br />ASSIGNEDTO: <br />_t <br />e r„ a <br />EMPLOYEE#: <br />^Q <br />DATE: 'O /Do/C-;i <br />Date Service Completed (if already completed): <br />SERVICE CODE: <br />PIE: , (DO t <br />Fee Amount: <br />oo <br />Amount Paid Tio b <br />Payment Date <br />Payment Type <br />Invoice # <br />Check # <br />Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />