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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID # PHONE# Ems. SERVICE REQUEST # OWNER I OPERATOR i,�� \ �V; q ^ tC`\c V' L^ CHECK if BILLING ADDRESS� FACILITY NAME SITE ADDRESS Sheet Number Direction Street Name SAN JOAQUIN COUNTY city ZIP Code HOME or MAILING ADDRESS (If Different from Site Address) I �1 I a T Street Number v v R V ", SSt_reet Hem CITY g, -C Y c, C ry o_h� EMPLOYEE #: 1�., Z Z .J STATE C ZIP O U PHONE #1 Em 0/c) Gac aa5a APN # LAND USE APPLICATION # PHONE #2 Exr. Date Service Completed (if already com feted): BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REOUESTOR CHECK If BILLING ADDRESS 1' \ BUSINESS NAME PHONE# Ems. HOME or MAILING ADDRESS FA%# ( 1 CITY 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.FE4� laws. APPLICANT'S SIGNATVRE-./ ^ r— �� ` DATE: C{ - PROPERTY/ BUSINESS OWNERM OPERATOR / MANAGER ❑ OTHER AUTHORIZED AGENT IfAPPLICAAT 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: COMMENTS: SEP Z 6 2022 SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT ACCEPTED BY: EMPLOYEE #: 1�., Z Z .J DATE: ASSIGNED TO: EMPLOYEE #: DATE: 2 - L Date Service Completed (if already com feted): SERVICE CODE: I": 1 Fee Amount:Amount Paid g — Payment Date Z Payment Type J Invoice # C # /5-c) ?J Received By: EHD 48-02-025 REVISED 11/17/2003 - F,07-,ZoI5 SR FORM (Golden Rod)