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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> M(�Oce % AP),40a� <br /> OWNER/OPERATOR <br /> 7e--, I co' 'D _ `.(/v CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> CjJ /t i ` J •, <br /> SITE ADDRESS L�(,(/(,V[' !U/'/ <br /> TStreet Number Direction Street Name City Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> CI cc W- Street Number Street Name <br /> CITY , A Ko V1 STA"q_ �IP� <br /> PHONE#'I EXT. APN# LAND USE APPLICATIOCN7#`] <br /> PHONE#2 EXT. EMAIL BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK if BILLING A06RE55 <br /> BUSINESS NAME PHONE# EXT. <br /> HOME Or MAILING ADDRESS FAx# <br /> ( ) <br /> CITY STATE ZIP 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 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: DATE: <br /> PROPERTY I BUSINESS OWNER❑ OP TOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT is not t !LLlNG 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 in rmation to the <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It Is available and at the Same time It is provi A[ my <br /> representative, <br /> TYPE OF SERVICE REQUESTED: it <br /> COMMENTS: `SNJ <br /> 4eNVIAOUIN C <br /> 1&atry a°pAR L <br /> ACCEPTEDAV <br /> 177- <br /> BY: EMPLOYEE#: DATE: 1 L) <br /> ASSIGNED TO: AUSM EMPLOYEE#: DATE: 14 <br /> Date Service Completed (if already completed): SERVICE CODE: PIE: <br /> Fee Amount: Amount Pai Payment Date <br /> Payment Type Invoice# Check# Recei d By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 03/22/23 <br /> ?R�-q W D <br />