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Type of Business or Property FACILITY ID # <br />CO <br />APN#Ext. <br />Ext.BOS District Location Code <br />Check if Billing Adores: <br />Ext. <br />APPLICANT’S SIGNATURE: <br />Employee #: <br />Employee#: <br />Amount PaidFee Amount: <br />Invoice # <br />SR FORM (Golden Rod)EHD 48-02-025 <br />03/22/23 <br />San Joaquin County Environmental Health Department <br />SERVICE REQUEST <br />^2^0 <br />Zip Code <br />________________Street Name____________ <br />State Zipca_____4^2. <br />Land Use Application # <br />5fc7-o <br />Street Number <br />j L/\- <br />State__________CA <br />5 <br />Direction <br />Home or MAILING Address (If Different from Site Address) <br />2^3^° 5eVlAC-bti LtA ■____ <br />Crr^+ocK--Yoin <br />Phone #1 <br />Phone #2 <br />() <br />Date: <br />Date: <br />lp/E:l^ <br />Received By: <br />LcA;________City <br />Service Code: | <br />Payment Date <br />Phone # _ <br />C2^)3z I-Z.(G <br />Fax# <br />( )__________________ <br />tAcffib yT g. L- cXvC co <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, Standards, State and Federal laws. <br />SERVICE REQUEST# <br />Check If Billing Adless <br />SfC 7~° <br />ACCEPTED BY: <br />Assumed to: <br />Date Service Completed (if already completed): <br />Payment Type i <br />Date: <br />Property/Business Owner EL Operator / Manager Other Authorized Agent ' C)Oj ia <br />If Applicant is not the Bilung 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. __________________________________PAYtor-.- <br />Type of Service Requested: id-fclA'___________________________________ <br />Comments: ApO <br />i 6 2021, <br />EMA'v i c-Von\ Lf ^Ue | <br />CONTRACTOR / SERVICE REQUESTOR <br />Requestor <br />\JIc+oyQxUp C<? <br />Business Name . <br />_________CO \f\f\CA TO~^ _____ <br />Home or Mailing Address <br />2<3»H.O Scyi/v q <br />Owner / Operator <br />Victoria ParW <br />facutyname <br />Site Address ( q <br />Street Number