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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property( FACILITY ID# SERVICE REQUEST# <br /> V-4 <br /> l�c.� QUI-•(, nC rC i.., ' S l�VJU/ 4Z T <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME Q ` <br /> FIC.- G l r,.) r k <br /> SITE ADDRESS talc's }I<� I Z FL <br /> v Z• <br /> 11�a <br /> S 6�t r Street Number Direction Street Name city Zip Code <br /> HOME or MAILING ADDRESS (if Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#t EXT. APN# LAND USE APPLICATION# <br /> (2°`I 33�(-2112 05'S7- tuo- 21 <br /> PHONE#2 EXr. EMAIL BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR CHECK if BILLING ADDRESS <br /> . ,C---tS <br /> BUSINESS NAME <br /> PHONE# EXT. <br /> Tc crc-cw. Cups..\��.-�S �.-.� Z�°► 3(s}-3 <br /> HOME or MAILING ADDRESS Fax# <br /> X02 k� IN ( ) <br /> CITY �� STATE C� ZIP °I$ EMAIL <br /> 'te'N .vyl"." 1a�tl Ti��tiGw•Ccln <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 FEDERAL laws, <br /> APPLICANT'S SIGNATURE: (/' _ % i i- DATE: I I 12 3 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ® (ten <br /> IfAPPLICANT is not the BILLING PARTY,proof of authorization to sign is required Title <br /> AYTHORIZATION TO RELEASE INFORIUTATIQN: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 to me or my <br /> representative. <br /> TYPE OF SERVICE REQUESTED: T <br /> COMMENTS: <br /> —� .� �'I e, SAIv NOV 4 ?0 <br /> �J JOA <br /> A1-TNCEPgRTORO U/ COU ry <br /> ACCEPTED BY: pt vL EMPLOYEE#: DATE: I 13 T <br /> I 3 <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: S7-3 PIE: Z&OZ <br /> Fee Amount: �8 DD Amount Paid .f�g- Payment Date <br /> Payment Type V,SyInvoice# Check# I g q '2-1 Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 03/22/23 <br />