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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> S;2 mm67�13( <br /> OWNER/OPETOR <br /> P, , Nb 1^ 1�� ,^ CHECK If BILLING ADDRESS <br /> FACILITY NAME Los <br /> VI.iLe <br /> SITE ADDRESS v T <br /> r"Street Number Direction Street Name City Zip Code <br /> HOME or MAILING <br /> /ADDRESS f Different from Site,Ad ress) l /� 1 �Q` <br /> ` ✓�` Street Number I��n1/L tom'' 0 Sat Name <br /> CITY C'+U �� STATE Zip —^' <br /> PHONE#'I /"1°//SY EM. APN# LAND USE APPLICATION# \�•�' J <br /> (VA �-f D-L+5 S <br /> PHONE#2 ExT. EMAIL BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR '— 'A I <br /> r� I' b I /n /� CHECK if BILLING ADDRESS 0 <br /> BUSINESS NAME ) (�S -FSS ,,v(((T/// 1 ((/--�wiCA' PHAy�# 3�•0` �s • <br /> HOME or MAILING ADDRESS FAX# (� <br /> CITY STATE r A ZIP i1 MAIL' r , ( O J <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: 9 /ate <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT is not the BILLING PARTY,proof of authorization to sign is required Titre <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 43AA, �P�d to me or my <br /> representative. I z W <br /> Nr <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: SEP 0 <br /> 12023 <br /> Rt" <br /> NONCouloy <br /> !pAAkM T <br /> ACCEPTED BY: EMPLOYEE#: DATE: —3�-2 <br /> ASSIGNED TO: a; EMPLOYEE#: DATE: <br /> Date Service Completed (ifalready completed): SERVICE CODE: �Z3 PIE: ,wO <br /> Fee Amount: Amount Paid Payment Date / 23 <br /> Payment Type Invoice# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 03/22/23 <br /> VjZOSq qoo <br />