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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUUEE(STTJ# <br /> 1.✓ l <br /> Or/OPERA <br /> CHECK if BILLING ADDRESS[] <br /> FAClLI <br /> SITE AD RE5 <br /> Street Number Direction Street Name c[ty Zip Code+ <br /> HOME Or MAILING ADDRESS (If Different from Site Address) �/' <br /> Strout Number /r sytr(oet 5e / <br /> CITY SZIP <br /> C O�ir TAT �S2 r-2- <br /> PHONE <br /> PHONE#1 ExT. APN# LAND USE APPLICATION# <br /> 1 (; '� --I-ry <br /> PHONE#2 ExT. EMAIL BOS D;STRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> CL `� GHecx if SICCING AnDRr=ss❑ <br /> BUSINEss NAME PHONE# Exr. <br /> HOME or MAILING ADDRESS FAX# <br /> ( ) <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 farm. <br /> I also certify that I have prepared this application and at the work to be performed will be done in accordance with a!l SAN JOAOUIN <br /> COUNTY Ordinance Codes, Standard E d FE <br /> APPLICANT'S SIGNATURE: DATE: ,c r 23 <br /> PROPERTY/BUSINESS OWNER D O RATOR I M NA ER OTHER AUTHORIZED AGENT ❑� <br /> I/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'nformation to the <br /> SAN JOAOUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it Is pro yelu or my <br /> representative. <br /> TYPE OF SERVICE REQUESTED: _ EO AQ f2 fAA 1.0 <br /> COMMENTS: <br /> 7 3 zoz3 <br /> JEF�EgCNr f RDNM&N�uNrY <br /> H O�PpR ZMCM7' <br /> ACCEPTED BY: �C t1 EMPLOYEE#: DATE: !("7 z 2 <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> t <br /> Date Service Completed (if already completed): SERVICE CODE: 5 PIE: �� 1 <br /> Fee Amount: ff QX Amount Pat Qa Payment Date <br /> Payment Type Invoice# Check# �/� ��7 Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 03/22/23 <br />