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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> i ADZ112)s SQ(Mg--i325 <br /> OWNER/OPERATO <br /> ( CHECK If BILLING ADDRESS O <br /> !' \ <br /> FACILITY NAME <br /> L--J V-I, <br /> SITE ADDRESSts:Tee � 1 O S C v�nZv I,C U,\►\C <br /> umber Direction Street Name Cit Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) S 6 <br /> C\ Street Number Street Name <br /> CITY STATE ZIP <br /> C� 521 <br /> PHONE#t EXT. APN# LAND USE APPLICATION# <br /> rZGI �— Q — u <br /> PHONE#2 EXT. EMAIL BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> C G c c \ <br /> BUSINESS NAME PHONE# EXT. <br /> o ) t, Q — CG � <br /> HOME or MAILING ADORES FAX# <br /> Sc <br /> ( V ( ) <br /> CITY t G STATE \ ZIP C C 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 tat the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards, STA nd 7aws.l <br /> APPLICANT'S SIGNATURE: DATE: G Ct — Z 5 <br /> PROPERTY/BUSINESS OWNER❑ OP RATOR/ ANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT is not the LING 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 provld me or my <br /> representative. <br /> TYPE OF SERVICE REQUESTED: C.y--,CAn e- o� OLOniE.4 Shy p <br /> COMMENTS: <br /> F'vM,0gQ�?3 Zp23 <br /> y�TyO7,1?E qRT q�N�Y <br /> MFNT <br /> ACCEPTED BY:gY'1GVlh 2 1� EMPLOYEE#: DATE: km1231'2-3 <br /> ASSIGNED TO: u 6c, 3 EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE:�(�I PIE: <br /> Fee Amount:5IG2, W Amount Paid 00 Payment Date Z3 <br /> Payment Type Invoice# Check# 2 Recei ed By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 03/22/23 <br />