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(1e,� (-� e e dz <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT II tz <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> SR�C08��1�t <br /> OWNER/OPERATOR _ I <br /> CHECK If BILLING ADDRESS❑ <br /> FACILITY NAME s C <br /> SITE ADDRESS /^�// S `� l l <br /> 1.1.ber Di)rection StrFfet Name 1 1�U h� Code <br /> ` <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 ExT. APN# LAND USE APPLICATION# <br /> (20 ) a ),I - lel <br /> PHONE#2 ExT. EMAIL BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR I <br /> 11 r V\/ CHECK If BILLING ADDRESS <br /> BUSINESS NAME ` V ( 1 111 V P ONE# ExT. <br /> ^ee io C 31- I �1 � <br /> Ho M Or MAILING ADORES FAX# <br /> 1 ew C s <br /> CITY U � l 1 I STATE / ZIP _3 G ( ►N�� U S�i �(L lCO <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, Standard STAT and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: QomDATE: I` �, 20 ZI <br /> PROPERTY/BUSINESS OWNER 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 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. <br /> TYPE OF SERVICE REQUESTED: P �v1Sc�fivv� ��t e- QCti <br /> IRMMENT <br /> COMMENTS: REeEIVED <br /> JAN 16 2024 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY:—6 r;am V)e EMPLOYEE#: DATE: (D I I u t2 t4 <br /> ASSIGNED TO: VC,_C(eCLrV.,,r, l_ EMPLOYEE#: DATE: Cp 1 1 to Zy <br /> Date Service Completed (if already Completed): SERVICE CODE:CD(,1 P I : ,lp p 3 <br /> Fee Amount: x a 2 ,(2G) Amount Paid Payment Date 1 <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 03/22/23 <br /> P�ZO�-I g�IZ <br />