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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property ,yam If BILLING ADDRESS BUSINESS NAM ufrl bo FACILITY ID # SERVICE REQUEST # Y HOME or MAILING ADDRESS FEB 2 1 2023 Y D 2\ 3 O� OWNER I OPERATOR l ) CITU t\ mnt)1 STATE ZIP r y- ASSIGNEDTO: qe,( �(if CHECK If BILLING ADDRESS � 6- V� SERVICE CODE: FACILITY NAME PIE: U 2 Fee Amount: 5 Amount Paid I Payment Date 2 21 123 SITE ADDRESS w,` {(� �� d• Street Number OlreMlon Street Name Received By: city ZIP Coda NOME or MAILING ADDRESS (If Different from Site Address) Street Number Street Name CITY STATE ZIP fi -I -ax) to PHONE#1 En. APN # LAND USE APPLICATION # lacy ) k4 - PHONE#2 EaT. BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR O(\k rc,CHECK ,yam If BILLING ADDRESS BUSINESS NAM ufrl bo a ler er I c�, PHONE# E1. Dd( a Li >o - CAG HOME or MAILING ADDRESS FEB 2 1 2023 FAx# 1135 hr l ) CITU t\ EMPLOYEE #: 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, Standards, STATE an FEDERALLila-'APPLICANT'SSIGNATUt�R7IE: � � DATE: 2&I L-23 PROPERTY I BUSINESS OWNER -91 OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT ❑ IfAPPLICANT is not the B/LL/NG PARTY proof of autharization 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 envirotunental/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: C S COMMENTS: RECEIVED FEB 2 1 2023 �JOAQUIN COUNTY ACCEPTED BY:'' EMPLOYEE #: DATE: DEPARTMENT r y- ASSIGNEDTO: qe,( �(if EMPLOYEE #: DATE: Date Service Completed already completed): SERVICE CODE: PIE: U 2 Fee Amount: 5 Amount Paid I Payment Date 2 21 123 Payment Type Invoice # Check # Received By: EHD 48-02-025 SR FORM (Golden Rod) REVISED 11/17/2003