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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property J U L 11 2023 COMMENTS: FACILITY ID # SERVICE REQUEST # &0 BUSINESS NAMEPHONE# _ EXT. rr` rr2 v./ (20 9) a 1 ' HOME or MAILING ADDRESS Date Service Completed (if already completed): FAX# OWNER I OPERATOR n Ave. Fee Amount: ►ter I Qr) c TC7r t' STATE Ch ZIP CIS7��O CHECK If BILLING ADDRESS FACILITY NAME j r A L -O � nJP--�s L U '_ ft SITE ADDRESS q Syea # S'S�j �j ?j �L P -'1 C, /\Vc S.� c,IG Y\ Street Number Direction Street Name City Zip Code HOME Or MAILING ADDRESS (If Different from Site Address) 3q� I/-*c>Jjy1 Street Number Street Name CITY STATE ZIP S PHONE #'I EXT. APN # LAND USE APPLICATION # PHONE #2 Exr. EMAIL BOS DISTRICT LOCATION CODE i? -A ; I - c z) rn CONTRACTOR / SERVICE REQUESTOR REQUESTOR J U L 11 2023 COMMENTS: _ r r QY 1 rr Q,$ CHECK If BILLING ADDRESS BUSINESS NAMEPHONE# _ EXT. rr` rr2 v./ (20 9) a 1 ' HOME or MAILING ADDRESS Date Service Completed (if already completed): FAX# 3 LP n Ave. Fee Amount: CITY STATE Ch ZIP CIS7��O EMAIL 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: /1'1+iGt�- — DATE: ()I PROPERTY/ BUSINESS OWNER OPERATOR / MANAGER ❑ OTHER AUTHORIZED AGENT ❑ If APPLICANT IS not the BILLING 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 the release of any and all results, geotechnical data and/or environmental/site ass YMEW'on to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It Is available and at the same time RG�+CItlC�e or my representative. KKC C�vC TYPE OF SERVICE REQUESTED: J U L 11 2023 COMMENTS: SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT ACCEPTED BY: EMPLOYEE #: DATE: ASSIGNED TO: `� S ►�lG; ✓1-- EMPLOYEE #: DATE: Date Service Completed (if already completed): �1' SERVICE CODE: I N o PIE: Fee Amount: Amount Paid Payment Date '� , 2� Payment TypeCJ ft Invoice # Syea # S'S�j �j ?j �L I Received By: EHD 48-02-025 SR FORM (Golden Rod) 03/22/23