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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT f,`0 1 <br /> ` SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# X <br /> S(Z214071(�6 <br /> OWNER/OPERATOR <br /> / CHECK If BILLING ADDRESS® <br /> S lr <br /> FACILITY NAME <br /> SITE ADDRESSC R <br /> /C <br /> 117/ Street Number Direction Street Name �'C�G/C Zi Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) r,,-7C; / i J <br /> h C f' Street Number Street Narmet, v <br /> CITY ATE ZIP <br /> S <br /> a c' cC 15-30 <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (yov - 0v 1'39-066 - 13(" -OC2d <br /> PHONE#2 EXT. EMAIL BOS DISTRICT LOCATION CODE <br /> L r4e-!Zn <br /> CONTRACTOk / SERVI E REQUESTOR <br /> REQUESTOR <br /> L/C4 <br /> N � I Gl � CHECK If BILLING ADDRESS <br /> BUSINESS NAME / PHONE# EXT. <br /> � CI "( �cr r ca I I c1 1 / 1 �r? <br /> HOME or MAILING ADDRESS / FAX# <br /> U.),1171V � - �,nC'k kd 1 roc, I c ( ) <br /> CITYEMAIL <br /> STATE ZIP 2-5-30V C n71II017C/0 <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent o ame, <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 FEDERwS. <br /> APPLICANT'S SIGNATURE: X)"� DATE: <br /> PROPERTY I BUSINESS OWNER❑ PERATOR I MANA R loll V OTHER AUTHORIZED AGENT L <br /> IfAPPLICANT is not I7 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. P <br /> TYPE OF SERVICE REQUESTED: REC <br /> COMMENTS: <br /> >� or eni)�q .��sr �� /I SAN <br /> MAY 14 2024 <br /> 0 SAfV <br /> f1JOgQU1NALHlRA <br /> COUNT'Y' <br /> ACCEPTED BY: -Jac( C EMPLOYEE#: DATE: <br /> ASSIGNED TO: ILLI � � L EMPLOYEE#: DATE: 5`+L�t ZL4 <br /> Date Service Completed (if already completed): SERVICE CODE: PIE: ' 2 <br /> Fee Amount: •z m6o Amount Paid _ � U� Payment Date <br /> rp <br /> ayment Type I Invoice# Check# !U � Z Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 03/22/23 Is <br />