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FACILITY ID # <br />Street Number <br />Street Number <br />Ext.APN# <br />Ext.BOS District Location Code <br />Requestor <br />Business Name Ext. <br />Home or Mailing Address <br />City State Zip <br />d <br />APR 2 3 2024 <br />Date: <br />Date: <br />Fee Amount:Amount Paid <br />Payment Type <br />PAYMENT <br />received <br />EHD 48-02-025 <br />03/22/23 <br />an. <br />San Joaquin County Environmental Health Department <br />SERVICE REQUEST <br />t the work to be performed will be done in accordance with all San Joaquin <br />laws. , <br />Site Address <br />Mt# <br />o <br />Zip Code <br />SR FORM (Golden Rod) <br />_________________Street Name____________ <br />State Zip a______Z221L <br />Land Use Application # <br />Check if Billing Address O <br />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. <br />SERVICE REQUEST# <br />Check if Billing Address O <br />Direction <br />Home or Mailing Address (If Different from Site Address) <br />I (slO Co*?# I I <br />Phone #1 <br />(>?) W5 SZ,g>Cp <br />Phone #2 <br />( ) <br />Phone # <br />J__1 <br />Fax# <br />J__)_ <br />Email <br />City <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 forj^. <br />I also certify that I have prepared thisXppjp <br />County Ordinance Codes, Standar^ <br />APPLICANT’S SIGNATURE: / <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />z-4 <br />py <br />Received <br />Type of Service Requested: <br />Employee #: I 3 <br />Employee#: 2-^ <br />Service Code: <br />2— ~~ Payment Date <br />Check# <br />Accepted By: ----- <br />assigned to: <br />Date Service Completed (if already completed): <br />% <br />(Invoice # <br />ecbe<L (. <br />CONTRACTOR / SERVICE REQUESTOR <br />______________________________ <br />Type of Business or Property <br />.Owner/Operator^) / . i 1 t <br />/aciLITYNAME <br />A! <br />S%TI