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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property BUSINESS NAME/ FACILITY ID # HOME or MAILING ADDRESS e(A SERVICE REQUEST # ll r� � "CAacosi k—,C � b t SZ� oROV g 01 L-44"(„ �j J 1112 -71t l TL " 14( o( Qurry co UNne yEALty D _PAR 1 OWNER /OPERATOR ACCEPTED BY: CK if BILLING ADDRESS E] FACILITY NAME DATE: ASSIGNED TO: SITE ADDRESS �f� EMPLOYEE #: ` DATE: Date Service Completed (if already completed): Street/Number Direction Street Name Fee Amount: 2 i C!i Z}i`�Co�de HOME Or MAILING ADDRESS (If Different from Site Address) V Check # `5�3 lStreet Number Receiv d By: Street Name CITY AIWPA STATE PHONE#1 1) EXT. APN # _ • L - 63 LAND USE APPLICATION # PHONE #2 ( ) EXT. BOS DISTRICT D IrATIOP.CODE CONTRACTOR / SERVICE REQUESTOR CHECK if BILLING ADDRESS REQUESTOR & rIf:::; � &W /M 2 BUSINESS NAME/ EXT. HOME or MAILING ADDRESS e(A CITY STATE ZIP 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. I also certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, Standards, S n F ERA APPLICANT'S SIGNATURE: DATE: PROPERTY / BUSINESS OWNER ❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT ❑ If APPLICANT Is not the BILLING PARTY, proof of authorization to sign is required Title 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. DA a— TYPE OF SERVICE REQUESTED:1ZtV COMMENTS: G,,rS Vt,�f YIV 'AZzi- AWYW Y V t-L��. p �y ll r� � "CAacosi k—,C � b t SZ� oROV g 01 L-44"(„ �j J 1112 -71t l TL " 14( o( Qurry co UNne yEALty D _PAR 1 v ACCEPTED BY: EMPLOYEE #: DATE: ASSIGNED TO: EMPLOYEE #: DATE: Date Service Completed (if already completed): SERVICE CODE: D Fee Amount: 2 i Amount Pai �S�` D Payment D to 11142 Payment TypeInvoice # Check # `5�3 Receiv d By: EHD 48-02-025 SR FORM (Golden Rod) 07/17/08