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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property _ FACILITY ID# SERVICE REQUEST# <br /> 00� "] �' S'RmCD 8�-co 2 1 <br /> OWNER/OPERATOR <br /> CHECK if BILLING ADDRESS r <br /> ti <br /> FAcIUTY NAME <br /> SITE ADDRESS :3TLC) <br /> Street Number 1 Direction Sbeet Name city Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 Exr. APN# LAND USE APPLICATION# <br /> ('Pi) 7 i.S 7W,— <br /> PHONE#2 ExT. EMAIL EIOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR CHECK If BILLING ADDRESS❑ <br /> BUSINESS NAME PHONE# EXT. <br /> HOME or MAILING ADDRESS FAx# <br /> f ) <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 /> I 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 /> 1 h <br /> APPLICANT'S SIGNATURE: lAJ DATE: <br /> PROPERTY/BUSINESS OWNER W OPERATOR/'MANAGER, ❑ OTHER AUTHORIZED AGENT ❑ <br /> /f APPLICANT is not the BILLING PARTY.proof Of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION:When applicable, 1,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 environmentaVsite 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. P <br /> � N� c <br /> TYPE OF SERVICE REQUESTED: %� vl ' �� - t�' t VC G `C <br /> COMMENTS: <br /> EI 14C—t) <br /> JAN 16 ?024 <br /> SANX04EN QUI <br /> HEALT R0 N RTMAL Y <br /> NT <br /> ACCEPTED BY: `� l �2 EMPLOYEE#: DATE: i/ /z/v <br /> ASSIGNED TO: CEMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: C, A P/E: ,c - <br /> Fee Amount: /_Zr Q/�� Amount Pai 77 z 0� Payment Date !(� 2 <br /> Payment Type VI Iii Invoice# Check# I '7 �7 1 67 Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 03/22/23 <br />