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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> VAQ)m z(om() SC�mmB� 2�s <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> �• <br /> k 14 <br /> FACILITY NAMES <br /> SITE ADDRESS 5 � <br /> Street Number DirectionWA.WXQStreet Name It Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number `� Street Name <br /> CITY STATE ZIP <br /> 13`J zb <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> `l - G,k <br /> PHONE#2 EXT. EMAIL BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> �, 1 CHECK if BILLING ADDRESS <br /> l e '\ <br /> BUSINESS NAME _ PHONE# EXT. <br /> C <br /> HOME or MAILING A DRESS FAx# <br /> 5 `t a e�cQ Aoc <br /> CITY 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 FE <br /> APPLICANT'S SIGNATURE: DATE: 5/ Wa <br /> PROPERTY/BUSINESS OWNER 1P OP 0�/ A OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT is not the IL G PAR pro of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION:Whe 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: Ch0.n O F Uws-�er Sh-%0 fAYMENT <br /> COMMENTS: <br /> SEP 2 5 2023 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: �YIGv��n� �\ EMPLOYEE#: DATE: Ci l26 `2.3 <br /> ASSIGNED TO: EMPLOYEE#: DATE:q 1 26\23 <br /> Date Service Completed (if already completed): SERVICE CODE: QP/E: mZ <br /> Fee Amount: \b"L•PCG Amount Paid _ Payment Date �� �d�? <br /> Payment Type V Invoice# Cl kc # C� Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 03/22/23 <br />