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t <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property 4 FACILITY ID# ��SE`RAQJt �E� <br /> OWNER/OPERATOR <br /> 1 CHECK if BILLING ADDRESS❑ <br /> C7' t(1 <br /> FACILITY NAME <br /> —LLDiprection <br /> SITE ADDRESS22 , C��t r 1�=1 S i 3Tc�IG`To�7 J Street Number Street Name City, Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> J 'S I N Street Number Street Name <br /> CITY STATE ZIP <br /> 5T0C\')'ynly�— 2 203 <br /> PHONE#1 ExT• APN# LAND USE APPLICATION# <br /> ( J <br /> PHONE#2 Exr. EMAIL BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK if BILLING ADDRESS <br /> BUSINESS 14AME PHONE# ExT• <br /> C. L Y) (' ) <br /> HOME Or MAILING ADDRESS FAX# <br /> FC <br /> ITY STATE ZIP1'1�1 C)-) EMAIL <br /> v.� <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: fc�n,4A- k DATE: os- 0'4 .- 23 <br /> PROPERTY I 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 t0 me or my <br /> representative. <br /> TYPE OF SERVICE REQUESTED: !�(,f/-L f� �k <br /> COMMENTS: <br /> � T <br /> ACCEPTED BY: EMPLOYEE#: DATE: C7 2 <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: PIE: I J <br /> Fee Amount: �CAmount Paid / Payment Date 5 R[ 25 <br /> Payment Type Invoice# eck l �� Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 03/22/23 <br />