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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> a�a o -:�&O9 7q- 00 <br /> OWNER/OPERATOR <br /> V1- r Y C VVZ <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> e c-he I a G 5' <br /> SITE ADDRESS 2(i dUc:I�- � <br /> Street Number Direction Street Name Ctt Zi Codc <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#'I EXT. APN# LAND USE APPLICATION# <br /> &q) -'IS-- LI II C13 <br /> PHONE#2 EXT. EMAIL B05 DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS❑ <br /> BUSINESS NAME PHONE EXT. <br /> 1'}Je- A C C la r4 ct� -Z � I S- q 1 a3 <br /> HOME or MAILING ADDRESS J + FAx# <br /> 2 ) <br /> 0 3 � F. 5' S <br /> CITY�� cx"` V 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 Of 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 yrr to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards, STAT�d-FEDERAL W - �7 <br /> APPLICANT'S SIGNATURE: �_— DATE: �1 S G L' <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> IfAPPLlCANT jS 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 andlor 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: o <br /> COMMENTS: <br /> 4PI? p �D <br /> h N�0. QUiN� 2�9� <br /> '�9CT DOpM�CO UN7y <br /> ACCEPTED BY: Y, EMPLOYEE#: DATE: +!�-Zo <br /> ASSIGNED TO: Ui ji {`rj _� EMPLOYEE#: DATE: <br /> 1/ <br /> Date Service Completed (if already completed): SERVICE CODE: Z 2� PIE: Q <br /> Fee Amount: i Amount Pai ?I— O(� Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 03/22/23 <br />