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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQ`U�EST# <br /> 59 <br /> OWNER/OPERATOR <br /> C' CHECK If BILLING ADDRESS❑ <br /> FACILITY NAME <br /> �. S44 cfZ e�� e L 51T�DO >�S` ` `�� C"--!�� ky-N �1 r(�r'—T X\Q C <br /> l� v� <br /> Street umber pirocto0 street Name cityZI Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> t C� Street Number Street Name <br /> CITY 5 TE ZIP <br /> C <br /> PHONE#1 Exr. APN# LAND USE APPLICATION# <br /> PHONE#2 Exr. EMAIL BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR CHECK if BILLING ADDRESS[:] <br /> BUSINESS NAME 1 P ON EXT. <br /> HOME orMI If ING ADDRESS FAx# <br /> �-r- « Q 1',' ';� <br /> CITY �C� STATE C 1 �S3y ZIP C r 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 ENVIRONNIENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity <br /> wilt 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 be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards, STATE and FEDERAL la <br /> APPLICANT'S SIGNATURE: DATE: L 2 <br /> PROPERTY I BUSINESS OWNER❑ OPERA ANAGER OTHER AUTHORIZED AGENT ❑ <br /> If AppLICANT is not the B1L ARTY,proof of authorization to sign is required Tille <br /> AUTHORIZATION TO RELEASE INFO ATION: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 JOAOUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available,and at the same�rr1P t�i,��pVJpd to me or my <br /> representative. AA MM NN <br /> RECEIVED <br /> TYPE OF SERVICE REQUESTED: Pl'Vt C vc — <br /> COMMENTS: Y 01r,H rL C <br /> SAN JOLJAQUUIVN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO; EMPLOYEE#: DATE: <br /> Date Service Completed (if already COmpleted): SERVICE CODE: �2— Pi O <br /> Fee Amount: Amount Paid Payment Date 2- <br /> Payment Type Invoice# ck# 1 7 D Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 03/22/23 r <br />