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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> ��-twa) 0 G wA y 544W -12 <br /> OWNER/OPERATOR <br /> k CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS A.-A.. <br /> �,� {� �G� <br /> V <br /> Albe, Direction � trek e`t"`Name FS Ci TZIpCode <br /> HOME or MAILING ADDRESS (If Different from Site Address) /r ,1 q <br /> Street Number ` <br /> S Afreet Name <br /> CITY STATEn ,� ZIP <br /> }C)L , 1 C4u 1 ) C <br /> PHONE#1 ExT• APN# LAND USE APPLICATION# <br /> &I ) 12tI- <br /> PHONE#Z ExT. EMAIL BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR ^ CHECK If BILLING ADDRESSO <br /> BUSINESS NAME PHONE# ExT• <br /> Z29- 3P <br /> HOME or MAILING ADDRESS FAX# <br /> I ( ) <br /> CITY 1-13CiCI STATE ZIP r EMAIL <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 or activity <br /> will be billed to me or my business as identified on this form. <br /> also certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUINt <br /> COUNTY Ordinance Codes, Standards, STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT 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 above site <br /> address, hereby authorize the release of any and all results,geotechnical data and/or environmental/site assessment information to the <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as Soon as It IS available and at the Same time It IS promPAYMEfO iTy <br /> representative. RECEIvEM <br /> TYPE OF SERVICE REQUESTED: k e9G "41 ti <br /> COMMENTS: <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: `m [f G EMPLOYEE#: DATE: b _N-. <br /> U ASSIGNED TO: EMPLOYEE#: DATE: (12- U_f z <br /> Date Service Completed (if already completed): SERVICE CODE: PIE 1�� <br /> Fee Amount: C2(0 Amount Paid Iff S — Payment Date j ?� <br /> Payment Type vlc. k Invoice# ck# 3 Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 03/22/23 <br />