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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property. FACILITY ID# SERVICE REQUEST# &kA, OWNER I OPERATOR!,, CHECK if BILLING ADDRESS❑ FACILITY NAME SITE ADDRESS S p .� -I''IS9 5' ry streetN mber Dlrectlon ee✓Q s,(Zotreet N tc� 9 zI coDa� HOME or MAILING ADDRESS (If Different from Site Address) Street Number Street Name CITY STATE ZIP PHONE#t ExT' APN# LAND USE APPLICATION# (425) 2-M—I[AT5 PHONE#2 EXr. BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REOUESTOR \ OC\ `(\ CHECK If BILLING ADDRESS BUSINESS NAME '� ` r�� PH NE# HOME Or MAILING ADDRESS FAX# CITY f STATE ZIP _�t�— -)Oq 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 FEDERAL laws. APPLICANT'S SIGNATURE: 6S- n DATE: 3 /3/23 PROPERTY/BUSINESS OWNERfa OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ IfAPPLicAAT is not the BILLING PART)',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 environmeIlftDust c assessment information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and a me it is provided to me or my representative. rr .. Lft— TYPE OF SERVICE REQUESTED: D COMMENTS: U 11 /rT/7 d�QUIN C DEPgOUIVTV R%kT ACCEPTED BY: f,/�.-F'Cj (� EMPLOYEE M DATE: ASSIGNED TO: EMPLOYEE#: DATE: Z �'tj - Z� Date Service Completed (if already completed): SERVICE CODE: PIE: O Fee Amount: Amount Paid Payment Date 2 Payment Type LInvoice# �Ci7eck : 1,5b I^ s 0151;( Received By: EHD 48-02-025 REVISED 11/17/2003 {712003 ems` — Cbb SR FORM(Golden Rod)