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V SAN JOAQUINZUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST LIS79L;75 Type of Business or Property / �, ttt I ., aT� SERVICE SERVICE REQUEST # OWNER / OPERATOR BUSINESS NAME c `q �5r , „— CHECK if BILLING ADDRESS FACILI NAME PHONE '# EXT. I Vi `7S t . SITE ADDRESS�� j Street Number Direction p Street Name ' FAX # j _ QM C, C& � cityZi Code HOME Or ING AD RESS (If Different from Site Address) Street Number $TATEC, Street Name CITY SERVICE CODE: O le I STATE ZIP 5vat PHONE #1 EXT. 2 APN # Amount Paid 1 LAND USE APPLICATION # PHONE #2 EXT. ( ) Payment Type C � BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR / �, ttt I ., aT� CHECK if BILLING ADDRESS BUSINESS NAME pv'^ /7� s s � 11 v�C^ p/?y vv&-(-`-- I (V PHONE '# EXT. I Vi `7S t . HOME or MAIL ADDRE 9 DATE: FAX # CITY EMPLOYEE M 13 $TATEC, ZIP S3 LCD BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/Or project Specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as identified on this form. also certify that I have prepared this application an e work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, Standards, STATE a DERA WS. APPLICANT'S SIGNATURE: DATE: lG� PROPERTY / BUSINESS OWNER ❑ OPERATOR / MANAGER ❑ OTHERZED AGENT ❑ If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required Tifle AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It IS available and at the same time It Is provided to me or my representative. -TIPE OF SERVICE REQUESTEED///��2/ COMMENTS: -�O ` Vim" T� J I / pv'^ /7� s s � 11 v�C^ p/?y vv&-(-`-- I (V ACCEPTED BY: EMPLOYEE #: DATE: ASSIGNED TO: EMPLOYEE M DATE: Date Service Completed (if already completed): SERVICE CODE: O le I I P! E: Fee Amount: Amount Paid 1 Payment Date ,)I) a 6 Payment Type C � Invoice # Check # Received By: EHD 48-02-025 07/17/08 5R ORIEE(NCRId) FEB 2 6 2018 SAN JOAQUIN COUNTY uuCC ENVIRONMENTAL 11m, TAdirsmrml'r