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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> IRTT811-�+8l�) <br /> OWNER/OPERATOR CHECK if BILLING ADDRESS❑ <br /> FACILITY NAME <br /> W'; Z <br /> SITE ADDRE.S �j_�C "IrJ�C? <br /> U� Street Number Direction ` C `C 3treetVNam`e 1` C Zin Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) k'--Z l5 B 6 iKe <br /> Street Number Street Name <br /> CITYWA <br /> \ � STATE n J^ ZIP <br /> IVLVE <br /> W <br /> PHONE#t Exr, APN# LAND USE APPLICATION# <br /> (% )CU Z <br /> PHONE#2 ExT, EMAIL BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR t , <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAMEPHO # — EXT. <br /> HOME or MAILING ADDRESS FAX# <br /> GlVlL ( ) <br /> CITY STATE CA- ZIP q Vv° ll 2 EMAIL <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business own✓er, 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 an FEDERAL laws. <br /> APPLICANT'S SIGNATURE: �&� DATE: I �z <br /> PROPERTY/BUSINESS OWNER❑ OPKING <br /> TOR/MANAGER OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT is not the BIL PARTY,proo 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. r <br /> TYPE OF SERVICE REQUESTED: C, �kAn t UT OW nrx vJi P PAYMENT <br /> COMMENTS: RECEIVED <br /> MAN 0 4 2024 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> 14PA I TW DEPARTMENT <br /> ACCEPTED BY: 'B( �M EMPLOYEE#: DATE: ?)�(DL(' -1a <br /> ASSIGNEDTO: L C1'�C� EMPLOYEE#: DATE: ?J1(t1l,iZll <br /> Date Service Completed (if already completed): SERVICE CODE: P E: (0(p 2 <br /> Fee Amount: mG Amount Paid Payment Date )L-02. <br /> Payment Type Invoice# eck# Z Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 03/22/23 <br /> �R n��ol��to2 <br />