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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Type of Business or Property OWNER I �TQll— FACILITY NI $ITE ADDF CITY #1 PHONE#2 mpmq b (NAILING ADDRESS (If SERVICE REQUEST FACILITY ID # 3 3 Z 2 G✓s tion from Site Address) APN Exr. w>i-ee' SERVICE REQUEST # CHECK If BILLING ADDRESS G� STATE ZIP CA -` %�' LAND USE APPLICATION # BOS DISTRICT II LOCATION CODE ..�.r.,..nrnn iQVDA If'F RF.01JFSTOR 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, ST TE and FEDERAL laws. APPLICANT'S SIGNATURE: an DATE: PROPERTY/ BUStNESSOWNERcf OPERATOR /MANAGER ❑ OTHER AUTHORIZED AGENT 13 If APPLICANT is not the BILLING PARTY proof of authorization t0 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 environnicatallsite 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. �LJlr I1<L'1l. 1 Vl\ I vavar. ♦ �� C --- CHECK if BILLING ADDRESS 0 TOR PAYMENT Exr. PHONE # NAME EHOME COMMENTS: Wtt -pif FAx # MAILING ADDRESS V ' MAR 13 2023 STATE ZIP SAN JOAQUIN COUNTY 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, ST TE and FEDERAL laws. APPLICANT'S SIGNATURE: an DATE: PROPERTY/ BUStNESSOWNERcf OPERATOR /MANAGER ❑ OTHER AUTHORIZED AGENT 13 If APPLICANT is not the BILLING PARTY proof of authorization t0 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 environnicatallsite 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. EFID REVISED 11117/2003 11�-- /2 77 v�� SR FORM (Golden Rod) PAYMENT TYPE OF SERVICE REQUESTED: COMMENTS: Wtt -pif V ' MAR 13 2023 SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT ACCEPTED BY: EMPLOYEE#: 62-1 DATE: '"2 C7 2-3 ASSIGNED TO: EMPLOYEE #: DATE: 3 23 Date Service Complet d (if already complet d): SERVICE CODE: -61 P/ Z Fee Amount: 4�(� Amount Paid �f _ --- Payment Date � 2, Payment Type Invoice # Check # Received By: EFID REVISED 11117/2003 11�-- /2 77 v�� SR FORM (Golden Rod)