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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or P: perty FACILITY ID# SERVICE REQUEST# <br /> Mcw re Z 3 5 R O W 3 7a 2 Co <br /> OWNER/OPEMTOR V t „ CHECK If BILLING ADDRESS O <br /> FACILITY NAME <br /> SITE ADDRESS <br /> l.�'Street'Number Direction � L"t Street N� � Cit Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PH0NE#1 EXT. APN# LAND USE APPLICATION# <br /> PHONE#2 ExT. EMAIL BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR i 1�" <br /> �� CHECK If BILLING ADDRESS <br /> BUSINESS NAME _ /i PHONE# s Z ? E � <br /> HOME or MAILING ADDRESS FAX# <br /> ys <br /> CITY �� �6 .� STA E ZIP jt�2 V( 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 form. <br /> 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 9XDERALPWS. <br /> APPLICANT'S SIGNATURE: DATE: � <br /> � /4 <br /> PROPERTY/BUSINESS OWNER❑ �IYG <br /> R A GER ❑ OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT is not the 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 t0 me Or my <br /> representative. PMMFNT <br /> TYPE OF SERVICE REQUESTED: 0 I 1s RECEIVED <br /> COMMENTS: <br /> SEP 2 1 2023 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: Ccwrvl Lo EMPLOYEE#: DATE: <br /> ASSIGNED TO: f� EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): 2 SERVICE CODE: �, P I E• Z <br /> Fee Amount: Amount Paid Payment Date ;2- <br /> Payment <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 03/22/23 <br />