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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> FA0004:(-o4SR00"S7079 <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS ZrJ3Z MGin % F�OCIC-fan zI520s <br /> Street Number Direction Street Name Cit Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> C� �) Street Number Street Name <br /> CITY ` STATE ZIP <br /> (�(�i'�►'1 f Z l Z <br /> PHONE#t ExT. APN# LAND USE APPLICATION# <br /> PHONE#2 EXT. EMAIL BOS DISTRICT LOCATION CODE <br /> 71 <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> hxleh Roffiet �cFI <br /> HOME or MAILING ADDRESS FAX# <br /> ( ) <br /> CITY C/_ STATE C ZIP 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 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: DATE: 0 ZS <br /> PROPERTY/BUSINESS OWNER❑ OPE TOR/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 I Is provided to me or my <br /> representative. AYMENT <br /> TYPE OF SERVICE REQUESTED: C\1r\0 C Q C)F Owner sh P RECEIVED <br /> COMMENTS: OCT 0 6 2023 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: 5. I(I,lW a EMPLOYEE#: DATE: I O c O^► ? <br /> ASSIGNED TO: C. muco EMPLOYEE#: DATE: I O �J� <br /> Date Service Completed (if already completed): SERVICE CODE: Q(o 1 P/E:1 V1Q)•Z <br /> Fee Amount: $� (u(I) Amount Paid 162— Payment Date �/� 3 <br /> Payment Type 7 Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 03/22/23 <br />