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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> SIT <br /> E 'DDI/ J �1 �I l�7'�' "10 <br /> 1 Street Number Diction C�� tTeet Name 1 I City Zi Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#t EXT. APN# LAND USE APPLICATION# <br /> ( <br /> PHONE#2 ExT. EMAIL BOS DISTRICT LOCATION CODE <br /> ( <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHON EXT. <br /> HOME Or MAILING ADDRESS FAX# <br /> L, O� S Cr' <br /> CIY ,' J l STATE ZIP EMAIL uj'xKJ 6 -'1 d ' (I <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 thi STATE <br /> and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standard , STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: <br /> PROPERTY/` U$ SINESWNE OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ �� �} y� �� <br /> /fI PUCANT 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 provided t0 me Or my <br /> representative. <br /> TYPE OF SERVICE REQUESTED: 1()1,7 SeJ7�r'r0h RFCFIVFn <br /> COMMENTS: e Of' 060hCJ'§ p APR 1 1 2023 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: s��) EMPLOYEE#: �8(p�` DATE: OL1/l//Zm Z-S <br /> ASSIGNED TO: kA,'C' EMPLOYEE#: g82S DATE: 01-1111120Z3 <br /> Date Service Completed (if already completed): SERVICE CODE: TO I/E: <br /> Fee Amount: r P� Amount Paid S� Payment Date /� a 3 <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 03/22/23 <br />