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(fie e d2 I <br />S;tN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />CHECK If BILLING ADDRESS <br />FACILITY ID # <br />NOV 0 8 2022 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />SERVICE REQUEST # <br />SR��oi� <br />PHO E# E><r• <br />e <br />L L. <br />FAX# <br />OWNER/OPERATOR <br />,/1 <br />( ) <br />CHECK If BILLING ADDRESS <br />FACILITY NAME /S <br />SERVICECODE: SZ',% <br />PIE: iWVl <br />Fee Amount: q <br />SITE ADDRESS <br />— <br />PaymentDate(( %0 L Z <br />Payment Type U I <br />invoice # <br />// <br />C A # �a (O I D 3 f, <br />Street Number <br />Direction <br />Street Name <br />City <br />Zip Code <br />HOME or MAILING ADDRESS (If Different from <br />Site[�Address) <br />SR=SS' <br />2 CX <br />Street Number <br />Street Name <br />CITY LOCl/ <br />STATE C-0 ZIP 952 Z/O <br />PHONE#1 <br />Esse <br />APN # <br />LAND USE APPLICATION # <br />(20q) <br />459- V n <br />PHONE#2 Exr. <br />( , <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />CHECK If BILLING ADDRESS <br />6S lqo) oiler, <br />NOV 0 8 2022 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />BUSINESS NAME 7 <br />PHO E# E><r• <br />HOME or MAILING ADDRESS f /-� <br />2 CJ <br />L L. <br />FAX# <br />Ctrl rill T"te/' <br />EMPLOYEE M <br />( ) <br />CITY ! <br />r� <br />STATE Ga 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 />or activity will be billed to me or my business as identified on this form. <br />I also certify that I have prepared <br />COUNTY Ordinance Codes, Stand <br />APPLICANT'S SIGNATURE: <br />PROPERTY / BUSINESS OWNER❑ <br />application and that the work to be pert <br />STATE and FEDIawS. <br />be done in accordance with all SAN JOAQUIN <br />MANAGER ❑ OTHER AUTHORIZED AGENT <br />//i08� <br />If APPLICANT is n. 7e BILLING PARTY proof of authorization to sign is required Title <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, 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 JOAQUUN 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 />PAYMENT <br />TYPE OF SERVICE REQUESTED: '60ci PIAV1 C1 <br />uy— . RECEIVED <br />COMMENTS: <br />NOV 0 8 2022 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />ACCEPTED BY:rk <br />EMPLOYEE#: <br />DATE: <br />L L. <br />ASSIGNED TO: W <br />EMPLOYEE M <br />DATE: <br />Date Service Completed (if already completed): <br />SERVICECODE: SZ',% <br />PIE: iWVl <br />Fee Amount: q <br />Amount Paid <br />— <br />PaymentDate(( %0 L Z <br />Payment Type U I <br />invoice # <br />// <br />C A # �a (O I D 3 f, <br />Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 VV O`5q y I2- <br />