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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST ?I�z0SL4S�-q� <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> TA00 `1o 'gD <br /> OWNER/OPERATOR CDC,( A C-C— v f^ 1 cAl C r CHECK if BILLING ADDRESS <br /> FACILITY NAME �`TL7G�ll �-C. \fM L� vlX c )�� 1i <br /> SITE ADDRESS I'13 ` � lrc cSZ �S <br /> Street Numbe I Direction Y Street Name City Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) '� I GLI <br /> Street NumberT `C' Street Name <br /> CITY C STATE n^ ZIP SZ.i S <br /> PHONE <br /> c m#1 � � � I ,`�� APN# LAND USE APPLICATION# <br /> U <br /> PHONE#2 Exr. EMAIL BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR CHECK If BILLING ADDRESS❑ <br /> BUSINESS NAME PHONE# EXT. <br /> HOME or MAILING ADDRESS FAX# <br /> CITY STATE ZIP EMAIL <br /> BILLING ACKNOWL MENT: 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 Ia/wS. <br /> APPLICANT'S SIGNATURE: -2y <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ 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 pr(A*j- me or my, <br /> representative. 7 (,� tYJ� <br /> TYPE OF SERVICE REQUESTED: 11 v� l/{;yr`l�"�}i'�V �"��� Ain. <br /> COMMENTS: <br /> H NViROIi/tv p1JN7'y <br /> N�EPgR M NT <br /> ACCEPTED BY. EMPLOYEE#: DATE: 2-3 <br /> ASSIGNED TO: iR EMPLOYEE#: ckp DATE: <br /> Date Service Completed (if already Completed): SERVICE CODE: PIE: <br /> Fee Amount: lo-- Amount Paid �� D� Payment Date v <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 03/22/23 <br />