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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business Property FACILITY ID# SERVICE REQUEST# <br /> r� l 0\ I P Q(98(o5SJ(0 <br /> OWNER I OPERATOR 1 CHECK if BILLING ADDRESS❑ <br /> C(�w%--") Co <br /> FACILITY NAME <br /> SITE ADDRESS <br /> Street Number Direction Street Name Clt Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY `` STATE ZIP <br /> 0-)Cx IN C{'C'.�'�- <br /> PHONE#'I EXT. APN# LAND USE APPLICATION# <br /> PHONE#Z EXT BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR , \ CHECK If BILLING ADDRESS❑ <br /> P <br /> BUSINESS NAME PHONE# EXT. <br /> H04E or MAILING ADDRESS FAX# <br /> CITY 1�� I r C_ ,,:L 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 /> APPLICANT'S SIGNATUUR�RE: ���� �V�I DATE: 3" o��—.�0.3t <br /> PROPERTY/BUSINESS OWNE 6 OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT 11If APPLWAN/lT iS not the BILLING PARTY,proof of authorization to sign is required Title ppAA qq��qq�� <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property loca!!;d"iltYtMENT <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site aREGEIVED <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. MAIC 2 9 2023 <br /> TYPE OF SERVICE REQUESTED: SAN JOAQUOI COUNTY <br /> COMMENTS: u t �er\� �J LNVIRN ENTAL <br /> V1/1\ HEALTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE#: (,P ',7f 3 DATE: <br /> ASSIGNED TO: EMPLOYEE#: .g S2 4 DATE: ` <br /> Date Service Com leted (if already completed): SERVICE CODE:cUJ P, <br /> Fee Amount: Amount Paid l Payment Date <br /> Payment Type Invoice# Check# �2 s(} Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />