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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />BUSINESS NAME <br />FACILITY ID # <br />� 0022gS3 <br />ERVICE R QUEST # <br />S 00 (0 (Z 9 <br />OWNER / OPERATOR <br />d (> Cis A S <br />1)�`/�t�� <br />(� <br />JA l �A <br />CHECK If BILLING ADDRESS <br />FACILITY NAME ^ .� �i' A! <br />t/1 <br />SA Lo <br />I� <br />DATE: <br />SITE ADDRESS �I 0,-1 <br />/Street Number <br />,i <br />Direction <br />SERVICE CODE: ( <br />+ �'� �,,' <br />l �I,— <br />t' 'Sltreet Name <br />city <br />Amount Paid <br />(� <br />l S20S <br />Zip Code <br />HOME Or MAILING ADDRESS (If Different from Site Address) <br />�t ( <br />S[reet Number <br />L Apo'-(e4c' <br />Street Name <br />Cj� <br />CITY /� t� �N , <br />a'! Iv�t "� <br />A ZIP <br />STATE CA— <br />APPLICATION# <br />01 5-Z') S <br />PHONE #1 l E�, <br />(XI) ���o— <br />APN# <br />LAND USE <br />PHONE#2 Ezr. <br />( ) <br />BQS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR---,--' <br />REQUESTOR <br />CHECK If BILLING ADDRESS <br />BUSINESS NAME <br />PHONE # EXT. <br />HOME or MAILING ADDRESS <br />FAx# <br />( ) <br />CITY STATE ZIP <br />BILLING ACKNOWLEDGEMENfI, 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 an at the work to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards, STATE . D . AL laws. <br />APPLICANT'S SIGNATURE: DATE: 12 2-1 2 % <br />PROPERTY/ BUSINESS OWNER 13 OPERA OR/MANAGER ❑ OTHER AUTHORIZED AGENT El <br />IfAPPL/CANTis not the BILLINGPARTY 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: '�%� J�V Vt V l�MeN T <br />COMMENTS: <br />Nvcu <br />DEC 2 7 2022 <br />SAN JOAQUIN <br />NSFNVIR EN N1Y <br />ACCEPTED BY: <br />EMPLOYEE #: <br />DATE: 1 ZZ <br />ASSIGNED TO: <br />EMPLOYEE #: <br />DATE: <br />Date Service Completed (if already completed): <br />SERVICE CODE: ( <br />PIE: <br />Fee Amount: S� / <br />Amount Paid <br />l <br />Payment Date 12 -Z—;:?q2 2 <br />Payment Type <br />Invoice ## <br />Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 b I w <br />