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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Od-\ C) <br /> OWNER/OPERATOR <br /> / CHECK if BILLING ADDRESS O <br /> FACILITY NAME <br /> S k Al ( U <br /> SITE ADDRESS L (� 2 qO <br /> i `" �� o-v ove-e °d I ff l V <br /> 1 \ Street Number Dirion ame Cit Zi Code <br /> HOME or MAILING ADD IRE S (If Different from Site Address) <br /> Gl Street Number \� 1 Street+Name <br /> CI STATE ZIP, . <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> PHONE#2 EXT. EMAIL BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINE S NAME 1•; (ll PHONE# EXT. <br /> HOME or MAILING ADDRESS FAX# <br /> CITY 1 STATE ZIP EMAIL <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized aged 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 FE ERAL <br /> OA PLICANT'S SIGNATURE: DATE: -` <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 PAYMENT <br /> COMMENTS: RECEIVED <br /> /� I^ MAK 11 2024 <br /> l�'l SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> r ^ H <br /> EALT <br /> ACCEPTED BY: S �(7 Il ll . . r\ EMPLOYEE#: DATE: <br /> ASSIGNED TO: WN\ EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: P I : \\-P <br /> Fee Amount: (�a Amount Paid Payment Date <br /> \/ <br /> Payment Type ��w Invoice# # Q/ Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 03/22/23 <br />