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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> �, ork4ZNJ I^ R.0 m S-7 8 g 3 <br /> OWNER/OPERATOR <br /> N <br /> .C,' I J CHECK if BILLING ADDRESS C� <br /> FACILITY NAME 1�l_� <br /> SITE ADDRESS <br /> Street Number I D ri ection �� � f�JStr�et Name <br /> HOME or MAILING <br /> ADDRESS <br /> Different <br /> Ci_fferefntt from Site Address) <br /> ^� <br /> Street Name <br /> CITY STATE ZIP <br /> PHONE A EXT, APN# LAND USE APPLICATION# <br /> PHONE#2 EXT• BOS DISTRICT LOCATION CODE <br /> { ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BLISINEss NAME J J V PHONE# EXt• <br /> HOME or MAILING ADDRESS PAX# <br /> Crit STATE 71 <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 <br /> or activity will be billed to me or my business as identified on this form. <br /> I also certify that I have prepared this application an at the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards, STA anK�fi 6ERAk laws. <br /> APPLICANT'S SIGNATURE: DATE;X- 3/28/2024 <br /> PROPERTY/BUSINESS OWNER OPER R/ AGER ❑ OTHER AUTHORIZED AGENT❑ <br /> IfAPPLiCANT is not t e �INF G ARTY proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE TION: When applicable, I, the owner or operator of the property located at the <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environmentaUsite assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: - REC MEAir <br /> COMMENTS: APR 01 <br /> 2014 <br /> SAH 1QAQUIN COU <br /> IVTV <br /> HEAL ND aMq RtTAL <br /> ACCEPTED BY: 1 A EMPLOYEE#: DATE: j <br /> ASSIGNED TO: Vti4 Ata <br /> v EMPLOYEE#: DATE: / J� <br /> Date Service Complet d (if already completed): SERVICE CODE: P, <br /> E: <br /> Fee Amount: Amount PaidPayment Date ass <br /> Payment Type Invoice# Check# Received y:AVZ <br /> EHD 48-02-025 /M SR FORM(Golden Rod) <br /> REVISED 11/17/2003 {� W <br />