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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 I QPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME -T <br /> SIT, DDRESS <br /> 5Tf ) + � <br /> Street Number Direction Street Name Cit Zi Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> ,r y <br /> 1 i"`.' I v" Street Number Street Name <br /> CITY STATE ZIP <br /> PHOMMEXT• APN# LAND USE APPLICATION# <br /> C-9 Zz I3IS <br /> PHONE#2 ExT. EMAIL BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUES OR CHECK if BILLING ADDRESS <br /> [ofl� dol )dLZJria�� <br /> BUSINESSNAMEerA <br /> o L, C— A "01 C <br /> Exr. <br /> HOME Or MAILING ADDRESS FAX# <br /> CrrY STATE ZIP EMAIL <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 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: e /: - 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 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 to me Or my <br /> representative. <br /> PAYMENT <br /> TYPE OF SERVICE REQUESTED: MA v I hS R <br /> COMMENTS: <br /> APR 2 6 2023 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED B EMPLOYEE#: DATE: 2 n —Z� <br /> ASSIGNED TO: EMPLOYEE#: DATE: `"W <br /> Date Service Completed (if already completed): SERVICE CODE: fll P I E: j <br /> Fee Amount: / Amount Paid l�J Paym`eJnit.(D'ate 4 2 2-O Z2, <br /> Payment Type V1 Invoice# Check# 1� Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 03/22/23 <br />