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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 />HOME or MAILING ADDRESS <br />SERVICE REQUEST # <br />CITY STATE ZJP <br />M 55 <br />AUG 01 2022 <br />S&& q00 <br />OWNER/OPERATOR <br />SANJOAQU/N <br />CHECK If BILLING ADDRESS <br />FACILITY NAME <br />\ �p <br />t <br />SITE ADDRESS O <br />Vv <br />C <br />0 c V<27 <br />>ZI <br />Street Number <br />Direction <br />Street NNaaae� V� <br />Cit <br />Cotle <br />HOME or MAILING ADDRESS (If Different from <br />Site Address) <br />SERVICE CODE: <br />0 <br />�1'� <br />/ZE V `Stre6l Number <br />Street Name <br />CIT( <br />Payment Date 4' / � <br />STATE ZIP <br />(/ TD A% <br />OH Z <br />PHrH NEE'R <br />APN # <br />LAND USE APPLICATION # <br />Check# �n <br />Received By: <br />PHONE#2 En. <br />( ) <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />CHECK If BILLING ADDRESS 13 <br />BUSINESS NAME <br />PHONE # Err. <br />HOME or MAILING ADDRESS <br />FAX# <br />CITY STATE ZJP <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 />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 that the work to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards, STATE d F 'DER aws. <br />APPLICANT'S SIGNATURE: / � — DATE: <br />PROPERTY / BUSINESS OWNER 13 OP BATOR / MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br />If APPLICANT is not the BILLING PARTY proof of authorizalian 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 />infornlation t0 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 />w_ <br />TYPE OF SERVICE REQUESTED: <br />I-AYiW <br />ENT <br />COMMENTS: <br />Ep <br />AUG 01 2022 <br />SANJOAQU/N <br />HEALTH DEpMET AL <br />ACCEPTED BY:baa M' <br />S <br />EMPLOYEE M <br />DATE: ' <br />ASSIGNED TO: <br />n/1 <br />EMPLOYEE #: r� <br />DATE: f' <br />Date Service Completed (if already completed): <br />SERVICE CODE: <br />P I UjO� <br />Fee Amount: t <br />Amount Paid <br />/� j&, U v <br />Payment Date 4' / � <br />Payment Type " K <br />Invoice # <br />Check# �n <br />Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />