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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />BUSINESS NAME <br />PHONE# Exr. <br />FACILITY ID # <br />FAX# <br />( ) <br />SERVICE REQUEST # <br />AN Z 1 2023 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />ACCEPTED BY: V. 217-aEMPLOYEE#: <br />\v d' <br />DATE: f '2. o1 <br />d9J3 <br />5R(Z08(oag3 <br />OWNER/ OPERATOR <br />• , <br />Date Service Completed (if already completed): <br />CHECK If BILLING ADDRESS <br />Re n <br />J <br />Ho res <br />Fee Amount: f 5� <br />FACILITYNAME R • , <br />I <br />K Y) IG <br />S ut <br />a <br />Invoice # <br />SITE ADDRESS )aa IVC <br />1le roh <br />Street Number <br />Direction <br />Street Name <br />Cil / <br />ZipCode <br />HOME Or MAILING ADDRESS (If Different from Site Address) <br />Street Number <br />Street Name <br />CITY <br />STATE ZIP <br />PHONE#1 <br />Ex . <br />APN # <br />LAND USE APPLICATION # <br />(SIO ) a34q- C9a6 <br />PHONE #2 <br />( ) <br />Exr. <br />BQS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />CHECK if BILLING ADDRESS <br />BUSINESS NAME <br />PHONE# Exr. <br />HOME or MAILING ADDRESS <br />FAX# <br />( ) <br />CRY STATE zip <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 <br />or activity 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. % <br />APPLICANT'S SIGNATURE: PP lu 9k rio res <br />PROPERTY/ BUSINESS OWNER El OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT 13 <br />If APPLICANT is not the BILLING PART}' 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 <br />above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment <br />information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available am Ete it IS <br />provided to me or my representative. <br />_ 10CP•GI\/CA <br />- - -- <br />TYPE OF SERVICE REQUESTED: <br />- <br />•�rvrr��r <br />COMMENTS: <br />AN Z 1 2023 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />ACCEPTED BY: V. 217-aEMPLOYEE#: <br />\v d' <br />DATE: f '2. o1 <br />d9J3 <br />ASSIGNED TO: <br />EMPLOYEE #: <br />a I <br />- 9 3 <br />DATE. 1.93-93 . <br />Date Service Completed (if already completed): <br />SERVICE CODE: 00 I <br />J <br />PIE: O <br />Fee Amount: f 5� <br />Amount Paid <br />L -s7z <br />Payment Date <br />L 3 2 - <br />Payment <br />Payment Type <br />Invoice # <br />Check # <br />Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />