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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of usi7s or Propert FACILITY ID# SERVICE REQUEST# <br /> �H'T <br /> OWNER/OPERATOR �J (��(r <br /> CHECK if BILLING ADDRESS <br /> FACILITY NAME 22 !Y1 S—I LC f_ <br /> SITE ADDRESS �7 �c�l� j,� "wE2 CeY Mearc -p <br /> Street NumberDirection Street Name City Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> 61-A l: I-�l�'I � M rzD, t\N-(2c( Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#'I ExT. AP # S'uQ I k LAND USE APPLICATION# / <br /> 636 <br /> PHONE#2 ExT. EMAIL t�)`22Gcsa3'TC C �G�t� BOS DISTRICT LOCATION CODE <br /> ( ) fA `C�� <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# ExT. <br /> r <br /> HOME or MAILING ADDRESS FAx# <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 FEDERAL laws. / <br /> APPLICANT'S SIGNATURE: DATE: ( 2?Z,2 2 y <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 t0 me Or my <br /> representative. <br /> TYPE OF SERVICE REQUESTED: C �-b PAYMENT <br /> COMMENTS: <br /> FEB 2 2 202 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE#:�o`ZF2 DATE: <br /> ASSIGNED TO: EMPLOYEE#: J DATE: <br /> Date Service Co pleted (if already completed): 0 SERVICE CODE: P I E:1,11707 <br /> Fee Amount: Amount Paid Payment Date Z 2y <br /> Payment Type = Invoice# 5-'Aa# I b Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 03!22/23 <br /> 1�v� ���� <br />