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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> SCzQG 6(a8LA'i <br /> OWNER/OPERATOR ^„ <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS <br /> I Street Number Direction Street Name city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> C- 1 i <^ 0 C14r,i I Street Number Street Name <br /> CITY STATE ZIP <br /> �-- <br /> PHONE#t Err. APN# LAND USE APPLICATION# <br /> ( ) 209AIS-3- Z4225- <br /> PHONE#2 ExT. EMAIL BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME i PHONE# ExT. <br /> en ( ,9- G63 4- 2S" <br /> HOME or MAILING ADDRESS FAX# <br /> me <br /> ( ) <br /> CITY STATE 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 F AL laws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERAT00 ANAGER ❑ 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 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 t0 me or my <br /> representative. PAYMENT <br /> TYPE OF SERVICE REQUESTED: Nti r P�Cu 1 4`t t LC RECEIVED <br /> COMMENTS: 11 1 N 16 <br /> 2023 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: UV�C'%- Yn — EMPLOYEE#:qEK0q DATE: (1(011(��LQ'Z3 <br /> ASSIGNED TO: (UC�X EMPLOYEE#: (perDATE: ZC'"L-, <br /> Date Service Completed (if already completed): SERVICE CODE:52') P I E:l(O(L j <br /> Fee Amount: Amount.Paid _ Payment Date �� <br /> Payment Type vI(24 Invoice# C ck# ���l) � Received By: <br /> EHD 48-02-025 pR 5,� g �- SR FORM(Golden Rod) <br /> 03/22/23 <br />