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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID# SERVICE REQUEST# J�ZW)8 -4(c-3 OWNER/OPERATOR CHECK If BILLING ADDRESS FACILITY NAME I 1 M 2� S .,• 1t � 7 SITE ADDRESS 2tiy� U.c Loi Street Number Direction ), ¢/Street Name Cit Zi Code HOME Or MAILING ADDRESS (If Different from Site Address) "1 2G Street Number Street Name CITY STATE ZIP PHONE#1 EXT. APN# LAND USE APPLICATION# (70.')2 -.39-� PHONE#2 EXT. EMAIL BOS DISTRICT LOCATION CODE ( ) CONTRACTOR / SERVICE REQUESTOR REQUESTOR I Ugoduv-, CHECK if BILLING ADDRESS BUSINESS NAME PHONE# EXT. P�� S v2 0'' ✓t � Z'`i S�-j �� HOME or MAILING ADDRESS FAX# CITY STATE ZIP �` EMAIL BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as identified on this form. also certify that I have prepared this ap catio an that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, Standards, ST EE a FE ERAL laws. APPLICANT'S SIGNATURE: /C DATE: PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ If APPLICANT is not the BILLING PART-,proof of authorization to sign is required Title AUTHORIZATION TO RELEASE INFORMATION:When applicable, I,the owner or operator of the property located at above site address, hereby authorize the release of any and all results,geotechnical data and/or environmental/site assessment i �r SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as Soon as It IS available and at the Same time it Is provl representative. y , �W M TYPE OF SERVICE REQUESTED: FF Con ud 11I v1A o n ?6 COMMENTS: EN OAQU/N HE,q�y p�R Ely)y NT ACCEPTED BY:"E>Y'�(;'y)n e M EMPLOYEE#: DATE: 21z(0 24 ASSIGNED TO: L f6 1(A b. EMPLOYEE#: DATE: .Z Date Service Completed (if already completed): SERVICE CODE: Qj( PIE: Fee Amount: ULZ.ob Amount Pai /4,� Payment Date Payment Type Invoice# Check# �� l I Receiv d By: EHD 48-02-025 SR FORM(Golden Rod) 03/22/23 ON S9(V2.