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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST INUSoo 1-Zq <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER 1 OPERATOR <br /> , CHECK If BILLING ADDRESS❑ <br /> Q0 <br /> FACILITY NAME <br /> Y-wiT. T <br /> SITE ADDRESS _ �t�� <br /> > Street Number Direction StQt 1aahSe f t Ci -lZlp <br /> J CQ <br /> HOME or MAILING ADDRESS (If Different from Site Address) _ �p y� <br /> "f et Number ` E� V'WESOM-0 me. <br /> CITY STrAXE <br /> q�� 0 <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> PHONE#2 EXT. EMAIL BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> \J <br /> (0 CHECK if BILLING ADDRESS❑ <br /> BUSINESS NAME PHONE# EXT. <br /> HOME or MAILING ADDRESS FAX# <br /> CITY STATE ZIP EMAIL <br /> _'+ 1 Q" C-A U <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 ad FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/M NAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> If 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 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. <br /> TYPE OF SERVICE REQUESTED: Chin e C O W Vie C S�1 PAYMENT <br /> COMMENTS: RECEIVED <br /> NOV 0 3 2023 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> A HEALTH DEPARTMENT <br /> ACCEPTED BY:aY tGl flit(" tv`. EMPLOYEE#: DATE: l 1 1(D a,'23 <br /> ASSIGNED TO:C'�'1 1 [ EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: (� PI E: (GQ 2- <br /> Fee <br /> Fee Amount:-���'-, .4 q Amount Paid 4{ L Payment Date L( 3 � <br /> Payment Type vi (-D Invoice# C # 1 a Z Received By: <br /> EHD 48-02-025 SR FORM(Golden Ro <br /> 03/22/23 <br />