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DocuSign Envelope ID: 3E840329-DB85-47BE-991B-A6FA17DO75C4 <br />%0Wr%%4v11n orvvnaI If P=,jVIRONMENTAL HEALTH DEPA E <br />SERVICE REQUEST COPY <br />Type of Business or Property <br />C1©NTlqA(CTOI? <br />�� Z � <br />FACILITY <br />ID # <br />SERVICE REQUEST # <br />Jl Z S �iZ� .sL p ok+I)0 <br />/447c) <br />/ 3 g <br />5 <br />ACCEPTED BY: <br />OWNER / OPERATOR <br />41 q <br />.o <br />Cf}ECKITBILLING ADDRESS <br />FACILITY NAME <br />ASSIGNED T0: <br />SITE ADDRESS�V h/� <br />Street Number <br />Cr7t{ <br />Direction <br />EMPLOYEE #: <br />C'� ,Q) <br />C� <br />Street tame <br />-�Q.�f <br />1 city/ <br />Zi Code <br />HOME Or MAILING ADDRESS (If Different from Site <br />Address) <br />•St'reet Nu mf ber <br />Fee Amount: <br />7� <br />s / Street Name <br />CITY � ne 41/ <br />(/�F/% <br />Date <br />STATE � ZIP <br />!%J 2 r�. <br />L <br />Invoice # <br />Check # <br />Received <br />By: <br />PHONE#1 <br />�j EXT, <br />APN I# <br />LAND USE APPLICATION # <br />PHONE#2 EXT• <br />( <br />BOS DISTRICT <br />LOCATION CODE <br />/ SERVICE IZE <br />BUSINESS NAME •� ~-�- i <br />HOME or MAILING ADDRESS�� �� <br />CITY <br />STATE <br />Fax # <br />CHECK if BILLING ADDRESS i <br />Exr. <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 <br />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 perf <br />ormed will be done in accordance with all SAN JOAQUIN <br />COUNTY OrCllnanCe COC/eS, StanC/aniS, STATE and FEDERAL IaW$. <br />/�—DocuSigned by: <br />APPLICANT'S SIGNATURE: Qstvtop <br />a DATES -:t 6/20/2023 <br />PROPERTY / BUSINESS OWNER P,P <br />A%fffl A,WA0 'GE2 OTHER AUTHORIZED AGENT Q I <br />If APPLICANT IS not the BILLING PARTY. (hoof of authorization to sign IS required / TiYtr <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the above <br />site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information <br />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 <br />my representative. <br />TYPE OF SERVICE REQUESTED: )//"c ©� 6,jV <br />EHD 48-02 <br />�� Z � <br />� � /iZr�� <br />•�"�/i <br />�' <br />COMMENTS: <br />ACCEPTED BY: <br />EMPLOYEE#: <br />DATE: <br />ASSIGNED T0: <br />EMPLOYEE #: <br />DATE: <br />Date Service Completed (if already completed): <br />SERVICE CODE: <br />PIE: <br />Fee Amount: <br />Amount Paid <br />Payment <br />Date <br />Payment Type <br />Invoice # <br />Check # <br />Received <br />By: <br />-025 SR FORM (Golden Rod) <br />07!17/08 <br />