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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> �(Z(bQ78foc1 <br /> OWNER/OPERATOR <br /> 1F- <br /> /` <lv�s `' 61,1S CHECK If BILLING ADDRESS <br /> FACILITY NAME ` <br /> SITE ADDRESS <br /> / �� � <br /> Street Number Direction Street Name :ityr [Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> e', Sr 'i Street Number Street Name <br /> CITY A STATE ZIP <br /> a <br /> PHONE#1 Err. APN# LAND USE APPLICATION# <br /> ( (Ql3 �(o3Z <br /> PHONE#2 ExT. EMAIL BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR / �< /� <br /> CHECK if BILLING ADDRESS <br /> BUSINESS NAME j /ac-' PHONE# Ex-r.47 421 1"66S- S. w( <br /> HOME or MAILING ADDRESS FAX# <br /> q031 -5 c- <br /> CITY STAT zip EMAIL <br /> C( ,- S-h <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 that t work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards, STATE FEDER I S. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER/SEINFORI.I?ATION: <br /> OPE ATOR GER ❑ OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT e BILLI RTY proof of authorization to sign is required Title <br /> AUTHORIZATION T RELE When applicable, 1,the owner or operator of the property located at the above site <br /> address, hereby authorize th rel 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:A4 h /.e Foo / -fnr eGl-ro h PAYMENT <br /> COMMENTS: RECEIVED <br /> JUIN 3 0 2023 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> H�AUH DEPARTMENT <br /> ACCEPTED BY: �Y�k Cly)n� M . EMPLOYEE#: 98�S DATE: -�&,`-2- <br /> ASSIGNED <br /> 2ASSIGNED TO: A."ade-anne. EMPLOYEE#:g58C) DATE: (o I* D I23 <br /> Date Service Completed (if already completed): SERVICE CODE: PIE: 2 <br /> Fee Amount: Amount Paid S�o Payment Date <br /> Payment Type V S Invoice# C "*V a Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 03/22/23 <br /> S <br />