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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST IW u5y%--4S7 <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> g � sr�mm 8�2�m <br /> OWNER/OPERAjOF <br /> CHECK if BILLING ADDRESS <br /> v qcf cw' O'n r tt��— <br /> FACILITY NAME- <br /> Tc- <br /> SITE ADDRESS <br /> reef Number Direction ►V 4u) <br /> W Street k3m� l V 'Citv do <br /> HO or MAILING ADDRESS (If Different from Site Address) <br /> 0 Street Number Street Name <br /> CITY j ^ STATE ZIP QJ� <br /> I/ fL Di L !/ <br /> PHONE#t EXT. API# LAND USE APPLICATION# <br /> ( o (; <br /> PHONE#2 EXT. EMAIL BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME/ <br /> � PHONE � EXT. <br /> a <br /> HOME Or MAILING ADDRESS ` FAX# <br /> ( ) <br /> CITY / Fo STATE /' ZIP EMAIL at <br /> , r <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 IBW Q <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MA GER ❑ 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 thpaove site <br /> address, hereby authorize the release of any and all results,geotechnical data and/or environmental/site assessment infuppA� <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It Is available and at the same time It IS provide <br /> representative. V <br /> TYPE OF SERVICE REQUESTED: D <br /> COMMENTS: J /1 FNVIR p U/N COV <br /> EACTy�FpAR MAt <br /> FNT <br /> ACCEPTED BY. EMPLOYEE#: ' ? DATE: (bb <br /> D 2-3 <br /> ASSIGNED TO: EMPLOYEE#: ^ J J DATE: <br /> Date Service Completed (if already com leted): SERVICE CODE: <br /> PIE: <br /> 2-- <br /> Fee <br /> Fee Amount: , �I Amount Paid /&� Payment Date 0/B <br /> Payment Type /l Invoice# Check# ' g Receded By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 03/22/23 <br />