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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> r—� M QL ^o�> u CHECK If BILLING ADDRESS❑ <br /> / I r! / <br /> FACILITY NAME\ <br /> v R J� l��J!ftJ Gv1sJs✓ <br /> SITE ADDRESS <br /> Street Number Direction Street Name city Zip Code <br /> HOME or MAILINGAADDRESS (If Different fromSite Address) L� <br /> 6 • f v/ ' ' FI Street Number Street Name <br /> CITYO C— �1 �TE ZIP <br /> 2 O- <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> PHON #2 ExEMAIL BOS DISTRICT LOCATION CODE <br /> -A%5,1 r�3 <br /> -J <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR dV/ <br /> (,.) CHECK If BILLING ADDRESS <br /> BUSINESS NAME )IJ /��� ��/��� PHONE C M ^ A /Y� EXT <br /> MAHII�HOME or AILING A DRESS N /V FAX# <br /> Wk <br /> CITY O t7� S ATEIP n p 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, ST�and FEDERAL laws. q <br /> APPLICANT'S SIGNATURE: q & 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 to me Or my <br /> representative. ,,l r <br /> TYPE OF SERVICE REQUESTED: P1 o �e I �ob I(e <br /> COMMENTS: RECEIVED <br /> DEC 2 8 2023 <br /> SAN JOAQUIN COUNTY <br /> � JJ ENVIRONMENTAL <br /> ACCEPTED BY:?56(Ay\o,e l"t• EMPLOYEE#: DATE: <br /> ASSIGNED TO: V,d c I -PEMPLOYEE#: DATE: <br /> Date Service Completed (if already co d): SERVICE CODE: rj 2 P 1 E:\t Q( 1 <br /> Fee Amount:' mount Paid Payment Date 2- <br /> Payment <br /> Payment Type Invoice# C # Z�� ` Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 03/22/23 <br />