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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 1=A 'L 3 -4 a m <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS❑ <br /> FACILITY NAME \ c o <br /> CA, C' i ^' <br /> SITE ADDRESS -4 ` , f Q 1 �Q 04 �+(� ys�p 6 <br /> Street Number Direction W o Yl Street Name City Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) syn CGS <br /> 1^ <br /> Street NumberTl, ` 5 U t r�� Street Name <br /> CITY MOA elb to <br /> o STATE ZIP <br /> PHONE#1 ExT. APN# LAND USE APPLICATION# <br /> (2 U ,/t <br /> PHONE#2 Exr. EM L BOS DISTRICT LOCATION CODE <br /> 2L ado <br /> CONTRACTOR / MERVICE REQUESTOR <br /> REQUESTOR <br /> QCJ ��O J � CHECK If BILLING ADDRESS❑ <br /> BUSINESS NAME lM PHONE# EXT. <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 FEDERA WS. <br /> APPLICANT'S SIGNATURE: DATE: 2 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER THEIR 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: <br /> COMMENTS: U �I.- <br /> Sgiy JO ?�t <br /> Ip�N� <br /> Nf{ <br /> ACCEPTED BY: r EMPLOYEE#: X1 13 DATE: d, K , `"i ,+ <br /> w/► II <br /> ASSIGNED TO: I^ LAV.® EMPLOYEE#: 13 8OC'a Q DATE: Q, `5 .oo 4 <br /> Date Service Completed (if already completed): SERVICE CODE: U O (PDaPIE: 1 !t1„ o a <br /> Fee Amount: 1 I_ Amount Paid I 2 ; Payment Date r 2 � <br /> Payment Type /1 `D Invoice# c�C �� Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) i <br /> 03/22/23 � G J �`^ <br />