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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> ��mm� t82s SRW8--Tm-is <br /> OWNER/OPERATOR <br /> on_ ( CHECK if BILLING ADDRESS❑ <br /> FACILITY NAME <br /> SITE A DRESS <br /> Street Number DirectSion ` tree S �" '— de <br /> HOME or MAILING ADDRESS, (if Different from Site Address) C jx <br /> �^t Street Number - Street Name <br /> CITY TATE t"3� <br /> PHONE#t EXT. APN# LAND USE APPLICATION# <br /> y 9g <br /> o $ <br /> PHONE#2 ExT. EMAIL BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR4tr+- {I <br /> (- CHECK if BILLING ADDRESS <br /> BUSINESS NAMEI D-S c1ru o5• P(92 Q ��D4b E <br /> HOME or MAILINGLA-DLJDRESS'' ,, II'' FAX# <br /> CI Tyt STA ZIP C� EMAIL <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 VIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project Or activity <br /> will be billed tome or my business as id I led on this fo <br /> also certify that I have prepared t appli tian/an hat the work to be performed will be done in accord nce with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standar s, ST andrF ERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: 762- <br /> PROPERTY/BUSINESS OWNER❑ PER /MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT Is n the BILLING PARTY,proof of authorization to sign is required Title <br /> AUTHORIZATIONT R L E INFORMATION:When applicable,I,the owner or operator of the property located at the above site <br /> address, hereby authori a release of any and all results,geotechnical data and/or environmental/site assessment information to the <br /> SAN JOAQUIN COUNTY ENWRONMENTAL 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:CV-,CO C e- C,Y 0�Yl�Y S�1�(� PAYMENT <br /> COMMENTS: KECEIVE D <br /> AUG 17 2023 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: �'t C�C1Y�'� EMPLOYEE#: DATE: `\ `2 <br /> ASSIGNED TO: C,\C,�-kcM cA, M EMPLOYEE#: DATE: !P> V1 2 3 <br /> Date Service Completed (if already completed): SERVICE CODE: P I E: y G/0 2- <br /> Fee <br /> Fee Amount:$\(o'L Amount Paid Payment Date ? 2 <br /> Payment Type V I Invoice# Cpe6l# �7 2) 2 Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 03/22/23 <br />