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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type/off Business or Pr perty C FACILITY ID # BUSINESS NAME SE(R�VIC�E REQUEST # q PHONE EXT. HOME Or MAILING ADDRESS�� Q i v �� ✓ L C �r (� (Ax # ) `�� CC OWNER/ OPERATOR , CHECK If BILLING ADDRESS 1 Jl ✓ L V l C/ v FACILITY NAME Fee Amount: SITE AD jRESSj �l Payment Date G� I-Y-I_`n F -Cr Payment TypeInvoice Street Number Direction Street Name Cit Zi Code HOME Or MAILING ADDRESS (If Different from Site Address) Street Number Street Name CITY STATE ZIP PHONE #1 EXT. APN # ayl3aol LAND USE APPLICATION # P4-aa0oa'3q PHONE#2 EXT. BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR I--�J q v �— V --'--,J Y V C CHECK If BILLING ADDRESS BUSINESS NAME ACCEPTED BY: Z' Z PHONE EXT. HOME Or MAILING ADDRESS�� Q i v �� ✓ L C �r (� (Ax # ) CITY / I O (f IL— —1c) t^ STATE ZIP �1 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 at the work to erforme will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, Standards, STATE EDERAL laws. \J APPLICANT'S SIGNATURE: r/Z� DATE: PROPERTY/ BUSINESS OWNER❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT /✓��K u 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: S- (+Gi G e �t l t i� Sv 6Su t`i COMMENTS: d REC c— o f-4 t�-e-tL-,� , BSEP 16 2022 �l1�IS� 1 S Its USSEsSVt�ei�� 5 �brn,}f C H M/1AQUIN O�IV1Y Ty NT ACCEPTED BY: Z' Z EMPLOYEE #: DATE: ASSIGNED TO: A5 EMPLOYEE #: DATE: Date Service Completed (if already completed): SERVICE CODE: r PIE: JS Fee Amount: Amount Paid �a • Payment Date (gyp 22 Payment TypeInvoice #-Gf�eck Received By: U EHD 48-02-025 SR FORM (Golden Rod) REVISED 11/17/2003