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San Joaquin County Environmental Health Department <br />SERVICE REQUEST <br />FACILITY ID # <br />i <br />Direction <br />Street Number <br />I City State <br />apn#Land Use Application #Ext. <br />EmailExt.BOS District Location Code <br />CONTRACTOR / SERVICE REQUESTOR <br />Requestor <br />Business Name Ext. <br />Home or Mailing Address <br />City State Zip <br />APPLICANT’S SIGNATURE: <br />Type of Service Requested: <br />Comments:APR 1 0 202't <br />Service Code: <br />Fee Amount:Amount Paid Payment Date <br />Invoice # <br />SR FORM (Golden Rod)EHD 48-02-025 <br />03/22/23 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />____________ <br />Check# Received By: <br />SERVICE REQUEST# <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 />^5339 <br />Zip Code <br />Strcot Name <br />Zip <br />Employee#: <br />Employee#: <br />Check If Billing Address O <br />Check If Billing Address O <br />Type of Business or Property <br />MJ f____________ <br />Owner I Operator , <br />, J 'J___ <br />h p <br />. StreetStreet Number <br />Home or Mailing Address (If Different from Site Address') <br />Phone# <br />J___L <br />Fax# <br />J__)_ <br />Email <br />Phone #1 <br />Phone #2 <br />( )__________________ <br />OWNL...------ <br />Facility Name <br />V <br />Site Address <br />Date: <br />Date: <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 />_________ Date: (rf 7/Cl / <br />Property / Business 0wnerJ3\ 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. PAYMENT <br />RECEIVED <br />Accepted By: 1 ) <br />aligned to: <br />Date Service Completed (if already completed): <br />Payment Type ... .