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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property;--)FACILITY-ID <br />_ Ser�iCe s Uti <br /># <br />+�ml(o5-i2 lr—SiZmma(0(02T <br />SERVICE REQUEST # <br />OWNER /OPERATOR <br />'7 O <br />NAM <br />' \W�" <br />CHECK If BILLING ADDRESS O <br />FACILITY NAME Cu Uy <br />18 2023 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />` 1 <br />�v <br />SITE ADDRESS I yU/_ <br />V �t7reat N ber <br />—{''; 'n <br />1 -I • '�-7 <br />Direction Street Name ✓ <br />CI <br />1,5 Z-Iq <br />21 Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />Street Number <br />Street Name <br />CITY <br />STATE ZIP <br />PHONE #t <br />(zoo}) 361 21 Li <br />En. <br />APN # <br />LAND USE APPLICATION # <br />PHO <br />( <br />O ! OZ 1 <br />� I <br />Ear. <br />EMAIL _ <br />U Y l <br />✓12 <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACT R / SERVICE REQUESTOR <br />REQUESTOR <br />CHECK IT BILLING ADDRESS <br />BUSINESS NAME <br />PHONE # Em <br />HOME or MAILING ADDRESS <br />FAX # <br />( ) <br />CITY STATE ZIP <br />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 projector activity <br />will be billed to me or my business as identified on this form. <br />1 also certify that I have prepared this application and that )thq work to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Ste dards, S A and FEDERAL raves. n <br />APPLICANT'S SIGNATUrrrR��� /I DATE: 17— <br />PROPERTY I BUSINESS OWNS j OPERATOR/ MANAGER 13OTH R UTHORIZED AGENT C3 <br />If APPLICANT IS t 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 itprovided pro idedd Nto Te or my <br />representative. PAro <br />TYPE OF SERVICE REQUESTED: <br />RECEIVED <br />COMMENTS: Cp,-g (1��J(' <br />440fAPR <br />18 2023 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />ACCEPTED BY: ` <br />EMPLOYEE#: <br />243 <br />DATE: <br />1 93 <br />l !/ <br />ASSIGNED TO:% <br />EMPLOYEE#: <br />DATE: <br />Date Service Corhpleted Of already com leted): <br />SERVICE CODE: <br />7 <br />I PIE!/t602, <br />Fee Amount: <br />Amount Paid lS _ <br />Payment Date � z <br />Payment Type yZ -7 <br />Invoice # <br />C # v <br />Receive By: <br />EHD 48-02-025 SR FORM (Golden. Rod) <br />03/22/23 <br />