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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID # BUSINESS NAME SERVICE REQUEST # Hair Salon & Spa 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 and FEDERAL laws. APPLICANT'S SIGNATURE: i"� i�Gi/LGCL/1i c%Ll.LGx DATE: 2/2/2023 PROPERTY /BUSINESS OWNER® OPERATOR /MANAGER ❑ OTHER AUTHORIZED AGENT ❑ If APPLICANT is not the BILL/NG PARTY, proof of authorization 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 Al release of any and all results, geoteclmical data Al enviromnental/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. PA 11m w _ TYPE OF SERVICE REQUESTED: % awl &ZIV eCel EHD 48-02-025 SR FORM (Golden Rod) REVISED 11/17/2003 COMMENTS: Body Art PermUnspection FEe 0 3 2023 SAE Jo HEALAQUIN C THRpEPgR M �TY T ACCEPTED BY: 61 ki Cii� 14 EMPLOYEE #: q DATE: o? ASSIGNED TO: EMPLOYEE M DATE: Date Service Completed (if already Completed): SERVICE CODE: O PIE: &0/10,1 Fee Amount: 0 166 Amount Paid 0 154 Payment Date 0? /07/a 3 Payment Type CTLGDI T Invoice # Check # JS64Z73Gg Received By: EHD 48-02-025 SR FORM (Golden Rod) REVISED 11/17/2003