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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# VICE REQUEST# <br /> � a11ei, CIO Z Z <br /> IbLn <br /> OWNER I OPERATOR <br /> CHECK If BILLING AD DRESS D <br /> FACILITY NAME r I <br /> f c t vt • IOU <br /> C LC- <br /> SITE ADDRESS Zy T� C� C. IOU `"[ �^e o 6 <br /> Street Nvmher Diroetion �" r beet Name cityZi Code <br /> HOME or MA LING ADDRESS (If Different from Site A dress) <br /> •, i [ �i <br /> Street Numbar Street Name <br /> CITY L STATE Z, Ze <br /> PHONE 01 Exi. APN# LAND USE APPLICATION# <br /> (14 ) .7q0r3�i <br /> PHONE#2 ExT, EMAIL BOS DISTRICT LOCATION CODE <br /> ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR I <br /> J '. �/�I t.�J4 CH,ECH If BILLING ADDRESS <br /> BUSINESS NAME PHONE# ExT, <br /> f-tue f4c/�f L x e ",? y <br /> HOME or MAILING ADDRESS r Wdei, FAX# <br /> c <br /> CITY ['�{lj STATE/ _ ZIP C 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 an FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE <br /> e1 ZLL;:� <br /> Z <br /> : ` <br /> PROPERTY/BUSINESS OWNER❑ OP ATO ANAGER ❑ OTHER AUTHORIZED AGENT [IIf APPLfCANT is nOt the Bf LING 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 prQyided to me or my <br /> representative. r AY <br /> TYPE OF SERVICE REQUESTED: L�1Gn e- QT <br /> COMMENTS: <br /> AUG SA/V Jp <br /> ZNVIRQU'IV CdU <br /> '��LTy D�A4R��NT?' <br /> ACCEPTED BY: EMPLOYEE#: DATE:: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Comple ed (if already completed): SERVICE CODE:Q!(6 l P I E:y VAI, <br /> Fee Amount: �IQZZAIG; I Amount Paid 17� Payment Date 2 <br /> Payment Type Invoice # Check# /9� lSt2c Receiv d By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 03/22/23 ��0 <br /> t, i <br />