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IDho.l�� <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT P�I 0 S Z z 2 t <br /> SERVICE REQUEST 1� J <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> FAWI5-7a(0 sRmm m4 <br /> OWNER/OPERATOR <br /> CHECK if BILLING ADDRESS <br /> —fir v <br /> FACILITY NAME , <br /> SITE ADDRESS <br /> Lao W GO�� y�E R� 1�� Ib <br /> Street Number Direction Street Name I Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) I.JJ V <br /> Street Number �U [) Mo Street Name <br /> CITY STATE ZIP <br /> c,P5- <br /> PHONE#i Esr. APN# LAND USE APPLICATION# <br /> (S-oo) -1 t -I t <br /> PHONE#2 En. BOS DISTRICT LOCATION CODE <br /> ( l <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME " PHONE# Eu. <br /> S JCL \ tJL o �S <br /> HOME or MAILING ADDRESS FAX# <br /> N N ( ) <br /> CITY _ p STATE 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 this application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: �, �=Z DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> If APPLICANT is not the BlLL(NG 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. <br /> TYPE OF SERVICE REQUESTED: <br /> i <br /> COMMENTS: <br /> MAR 16 2023 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: ZIA-aA%4l.00 EMPLOYEE#: DATE: 3 laola.3 <br /> ASSIGNED TO: K aL-e 0-v� EMPLOYEE#: DATE: 3/1 (0 a 3 <br /> Date Service Completed (if already completed): SERVICE CODE: P/E: ' oa <br /> Fee Amount: # 5(� Amount Paid Payment Date <br /> Payment Type V1 S Invoice# C ck# D S Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />