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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT P �I 0S -Z5 2 t SERVICE REQUEST 1� U Type of Business or Property FACILITY ID # SERVICE REQUEST # BUSINESS NAME " S \CtE \dJL FAWI5-7a(0 sRmm m4 OWNER/ OPERATOR FAX# CHECK if BILLING ADDRESS —fir v FACILITY NAME , SITE ADDRESS � 30 W G Off(, EMPLOYEE #: �� ] Ib Street Number Direction Date Service Completed (if already completed): Street Name I Zip Code HOME Or MAILING ADDRESS (if Different from Site Address) Fee Amount: # 5(� I.JJ V _--_ Payment Date Street Number �U [) Mo Street Name CITY C ck # 0 S STATE ZIP C,P5- PHONE#i Esr. APN # LAND USE APPLICATION # (S -la) -1 1-7, PHONE #2 ( ) En. BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR CHECK If BILLING ADDRESS BUSINESS NAME " S \CtE \dJL PHONE #_ Eu. o r SS HOME or MAILING ADDRESS MAR 16 2023 FAX# N SAN JOAQUIN COUNTY ( ) CITY _ p STATE ZIP 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, Standar7�� STATE and FEDERAL laws. APPLICANT'S SIGNATURE: , �=Z DATE: 3 *' PROPERTY/ BUSINESS OWNER❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT ❑ If APPLICANT is not the BlLL(NG PARTY 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 environmental/site assessment information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. TYPE OF SERVICE REQUESTED: r;—'QdnA�e. 04 COMMENTS: MAR 16 2023 SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT ACCEPTED BY: tel. 00 EMPLOYEE #: DATE: 3 I (D a 3 ASSIGNED TO: Ka u0 -v , EMPLOYEE#: DATE: 3/1(0/13 Date Service Completed (if already completed): SERVICE CODE:P / E: ' oa Fee Amount: # 5(� Amount Paid _--_ Payment Date 3 I 2 - Payment Payment Type V1 S A Invoice # C ck # 0 S Received By: EHO 48-02-025 REVISED 11/17/2003 SR FORM (Golden Rod) t