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SAN JOAQUIN COUNTY ENYHtONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 0� ,7 y200 ss <br /> OWNER I OPERATOR�{ <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME ch�J <br /> SITE ADDRESS i loll MtiT[-..(�I�GI <br /> Street Number Oirecllon Street Name city ZIn Code <br /> HOME or MAILING ADDRESS (If Differentfrom Site Address) <br /> ( 7 CD '`'7 r R.i !tel Street Number Street Name <br /> CITY 1 STATE / /j ZIP <br /> xAPPLICATION <br /> PHONE#1 / E . APN# LAND USE AAPPP/LIICCATION# C/ <br /> (ZIT Z -2 2 <br /> PHONE#2 Ev. BOS DISTRICTI LOCATION CODE <br /> ( ) '660 LJI <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADD SS <br /> BUSINESS NAME -FL-e-,#0 I u ke, oL -Z Z — 7?-,? <br /> HOME Or MAILING ADDRESS / L /� FAX# <br /> CITY LOG 'A� STATE l- ZIP /? <br /> BH-LING 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 and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STATE td FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER ERATOR I MANAGER ❑ 0THER AUTHORIZED AGENT 11 <br /> I-APPL/CANT is not the BILLING PARTY.proof of authorization 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 /> information to 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. pP <br /> TYPE OF SERVICE REQUESTED: dFij `�� •��C <br /> COMMENTS: Illi/Y vn/k� o MAR OZ <br /> `l. V 2023 <br /> a <br /> 1f�LL4lRDN IV C0 Nry <br /> DePART NNT <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNEDTO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: e6/ PIE: O <br /> Fee Amount: _ — Amount Pa' /S�• Payment Date y Z <br /> Payment Type Invoice# Check# /��g f �- Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br />- REVISED 11/17/2003 <br /> Pk0-5-Zz551 s <br />