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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> W cm-v- S i-by2 w 1 S n� ~cam S S Q (�)� IQ�)- D � <br /> OWNER/OPERATOR <br /> � A S CHECK If BILLING ADDRESS <br /> Lya <br /> FACILITY NAME t. <br /> ` ` Y, J CYC C Xy <br /> ADDRESS �A <br /> Direction Street NameZip 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 /> (2pc ) a <br /> PHONE#2 ExT• BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> C.,I vtl� CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# Exr. <br /> ( ) <br /> HOME Or MAILING ADDRESS FAX# <br /> ( ) <br /> CITY 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 /> 1 J' PPLICANT'S SIGNATURE: P DATE: <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> If APPLICANT 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 <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 /> 1 <br /> TYPE OF SERVICE REQUESTED: PAYMENT E <br /> COMMENTS: RECEIVED <br /> APR 12 2023 <br /> SAN JOAQUIN COUNTY <br /> HEE IRONMENTAL <br /> ACCEPTED BY: EMPLOYEE#: DATE: _ —Z <br /> ASSIGNED TO: EMPLOYEE#: DATE: '"C L—Z <br /> Date Service Completed (if already completed): SERVICE CODE: D /_ PIE, O 2— <br /> Fee <br /> Fee Amount: O Amount Paid l S�� __ Payment Date rY <br /> Payment Type Invoice# Check# l Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br /> S <br />