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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 'SCZmoD 8-q54-} <br /> OWNER/OPERAT R <br /> � riy t /t C„ CHECK If BILLING ADDRESS <br /> FACILITY NAM ,fin In e� _ Nyadisc— <br /> SITE <br /> 2R�S SUS �I� l, CisZo � <br /> Street Number Direction treet Name Ci Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> 27 2-1 jLv+1-P aStreet Number Street Name <br /> CITYy� <br /> (f-0- <br /> q 5 26-7 <br /> PHONE#1 EXT, APN# LAND USE APPLICATION# <br /> 5i7- L(`J <br /> PHONE#Z EST. EMAIL BCIS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> R QUEST R <br /> �q�t ` / CHECK If BILLING ADDRESS <br /> BUSINESS NAME S v n 1JZ KIP- �� PHONE# G ExT• <br /> �l/ 1 is/� ) S f � <br /> HOMor MAILING ADDRESS FAX# <br /> Z �Z,'l Zvi-It'd z W, ( ) <br /> CITY -t—p cI/-A-Cx\ STATE ZIP1 c ,-G 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, StandaST E an FE �ERALs.rdsw <br /> APPLICANT'S SIGNATURE: DATE: 12--11 -2 3 <br /> PROPERTY/BUSINESS OWNS PERATOR/MANAGER El OTHER AUTHORIZED AGENT [3If APPLICA r is not thb 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 pIffWat my <br /> representative. (� <br /> TYPE OF SERVICE REQUESTED: C h <br /> COMMENTS: 2023 <br /> SAN JOAQUIN COUN7y <br /> H�TM DEPART e <br /> ACCEPTED BY:by tUnn-e- VM EMPLOYEE#: DATE: <br /> ASSIGNED TO: ra -eanne L EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE:Okc PIE: UZ <br /> Fee Amount: $1(o'Z 06 Amount Paid X92 .� Payment Date 2 23/� <br /> Payment Type Invoice# CCU(I Received By: C"" 0 <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 03/22/23 <br /> PIR 0(5-23 (D 2- <br />