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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER I OPERATOR IS��� f1? �J T� O <br /> r CHECK If BILLING ADDRESS <br /> FACILITY NAME /fir' )—10r- .r) I 1<� <br /> SITE ADDRESS V r�-qc y bl ✓C) T(fC/G'\ X153 76 <br /> Street Number Direction I Street Name City Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> QStreet Number Street Name <br /> CITY STATE ZIP <br /> S lo C <br /> PHONE#t ExT. APN# LAND USE APPLICATION# <br /> PHONE#2 ExT. EMAIL BOS DISTRICT LOCATION CODE <br /> 2 36 �-l- oq <br /> bQ6 Q < <br /> CONTRACTOR / SERVICE QUESTOR <br /> REQUESTOR /f[� .f�/1 y� / <br /> � !` [� CHECK If BILLING ADDRESS❑ <br /> BUSINESS NAME MD--A07-9 �7 / PHONE# ExT. <br /> I ( _U11 — <br /> HOME <br /> l' — O <br /> HOME or MAILING ADDRESSn FAX# <br /> CITY Q TATE ^ ZIP L ,7 EMAIL/g (I q1)/'m 0, -:7 0 LW <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: "°�s DATE: ©� <br /> PROPERTY/BUSINESS OWNER[3 OPERATOR I 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 to me Or my <br /> representative. <br /> TYPE OF SERVICE REQUESTED: MC&'l'l r Q t'C'(,)CI TYUdc 1nS9 C+i0k-I ��d11Sl.L[I}C,�I1011) R <br /> COMMENTS: <br /> JUL 2 ? 2023 <br /> SAro <br /> AQUI <br /> IV 0p pqR ���, <br /> � ,t Nr <br /> ACCEPTED BY: t�jY 1C1Y�Y�e 1"t• EMPLOYEE#: DATE: 1 2 }1�3 <br /> ASSIGNED TO: V o_t ecnn e 1 EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: PIE: <br /> Fee Amount: ,ti,� Z Amount Paid cp 2 Payment Date <br /> 0 <br /> Payment Type Invoice# -� Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 03/22/23 <br />