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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> d � rA(Dm2��D�-8 SC�mm88m�8 <br /> OWNER/OPERATOR <br /> — � A C / f CHECK if BILLING ADDRESS <br /> FACILITY NAME`- �i I <br /> sf AC' UV 5 . I net Number Direction <br /> HOME r ILING AoPRESS (if ifferent from Site Address) eJrt� ,r <br /> Street Number "� Street Na�Yra <br /> CITY ST TE I <br /> PHONE Exr. APN# LAND USE APPLICATION# <br /> (20�,) <br /> PHONE#2 Exr. EMAIL BOS DISTRICT LOCATiON CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR _ <br /> r t�l •� CHECK If BILLkNG ADDRESS❑ <br /> BUSINESS NAME l PHONE# Exr. <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 /> I 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, St ngfcr J, TATIE and L laws. { <br /> APPLICANT'S SIGNATURE: DATES 1 � <br /> PROPERTY/BUSINESS OWNER❑ PERATOR 1 MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT is not��eOILLING 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 environmentallsite assessment information to tho <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: T N <br /> COMMENTS: D <br /> 5'^zy SAN jo <br /> �AQIJIIVENV <br /> � N� T�IRONM OE A✓7TTA1N� <br /> 114T <br /> ACCEPTED BY: EMPLOYEE#: 1 DATE: 6- 1 2- <br /> ASSIGNED TO: , EMPLOYEE#: !f DATE: <br /> Date Service Completed (If already completed): SERVICE CODE: ` PIE: <br /> ,;+ l <br /> Fee Amount: to W2, Amount Pali' ��, Do Payment Date 6 j j 2 <br /> Payment Type Invoice# ,}; Check# I�� ZI 7 f Received By: <br /> EHD 48-02-025 �"ln f SR FORM(Golden Rod) <br /> 03122/23 <br />