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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 1220- FA ©® a.0SqSR0® B-} 45 (2 <br /> OWNER 107 ATOR <br /> i � CHECK if BILLING ADDRESS <br /> FACILITY NAME / <br /> I Z Z�• 1 <br /> SITE ADDRESS C1�1 _ ��V� CA 152 0y <br /> Street Number Direction Street Name Cit ZiCode <br /> HOME Or LING D ESS (If Different from Site Address) ^x ` <br /> Street Number V Abeet Name <br /> CITY STATE ZIP <br /> scl <br /> PHONE#Z EXT. APN# LAND USE APPLICATION# <br /> ,M) Li- n `1 JAcSha <br /> PHONE#2 ExT. EMAIL I BOS DISTRICT I LOCATION CODE <br /> n $ - C Inan eZ Z IJw <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REOUESTOR CHECK if BILLING ADDRESS <br /> BUSINESS NAME-?, / PHONE# y ExT. <br /> s ' ZZa- cql` GSI-f 3 g <br /> HOME Or MAILING ADDRESS I LJ FAX# <br /> CITYtti ` $TATE Zip A CA cA I EMAIL ab0 V� <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: 11-7� <br /> PROPERTY/BUSINESS OWNER I OPERATOR/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 assessmen/�Information to the <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It IS available and at the Same time it IS pr me or my <br /> representative. <br /> TYPE OF SERVICE REQUESTED: 61, VE <br /> COMMENTS: fyuv-20 <br /> fyF NV2 <br /> 023 <br /> �TH�FPgRTM i��Y <br /> ACCEPTED BY: t 1`,2 EMPLOYEE#: DATE: 111/7 Z <br /> ASSIGNED TO: I 4, EMPLOYEE#: DATE: l( <br /> Date Service Compi ted (if already completed): SERVICE CODE: a PIE: <br /> Fee Amount: Amount Paid /l 2— d6 Payment Date /( �2-3 <br /> Payment Type Invoice# / Check# 17 216 S(Q Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 03/22/23 <br />