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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type o usiness or Py FACILITY ID# SERVICE REQUEST# <br /> 4.!, rAS(z(QtD$(05C� <br /> OWNER/OPERATOR <br /> CQS-1 CHECK if BILLING ADDRESS <br /> AM <br /> FACILITY NEby <br /> 1 <br /> SITE ADDRESS 's,010 1 N \! 1 15 VY� w rl y q§7-015 <br /> Street Number Direction Street Name r Cit p Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 2-1A15`1 G - An <br /> l I �.� 6�tfe t 4 <br /> Street Number Street Name <br /> CITYS-�o c- STATE ZIP�� <br /> PHONE#t EXT, APN# LAND USE APPLICATION# <br /> PHONE#2 Exr. EMAILBOS DISTRICT LOCATION CODE <br /> ( ) W aY, a e�Gl o G II ' (0n'1 <br /> C NTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR &AA <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <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 form. <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. 1 <br /> APPLICANT'S SIGNATURFrr SU� �;��„ Cad 1�eJjh1 DI: <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> /t APPLICANTtfs 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 isp ''tiIrl to me or my <br /> representative. 1ZIV <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: <br /> - . -� ?023 <br /> V VJ)oO/N COUN <br /> FALTy DEpgR At 7Y <br /> ACCEPTED BY: ' EMPLOYEE#: 1. 0 2 j DATE: / L3 <br /> ASSIGNED TO: `� EMPLOYEE#: `� 2-5 DATE: f Z <br /> Date Service Completed (if already co pleted): SERVICE CODE: E: l b� 7i <br /> Fee Amount: Amount Paid-'2) l Payment Date <br /> Payment Type Invoice# Check# 6-6 35D 711'1 Received By: ` <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 03/22/23 <br />