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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID# SERVICEREQUEST# OWNER/OPERATOR CHECK if BILLING ADDRESS FACILITY NAME SITE ADDRESS ` C�J^� �VC"�_ •{•S��.Y2S �Qw �.b��'J� ��2 Street Nu er Direction Jk Street Na me Ci Zi Code? HOME or MAILING ADDRESS (If Different from Site Address) Street Number Street Name CITY STATE ZIP PHONE#1 EXT. APN# LAND USE APPLICATION# PHONE#2 EXT. BOS DISTRICT LOCATION CODE ( ) CONTRACTOR/ SERVICE REQUESTOR REQUESTOR 1 i4�.C� _l 1 CHECK if BILLING ADDRESS BUSINESS NAME 1 =AFl7(`J(> �C PHONE ■ v� EXT• lri.� 4 0<— HOME or MAILING ADDRESS ( C tvw L-4 �-5 b ) CITY ST TE� 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, ST and FEDERAL laws. APPLICANT'S SIGNATU — DATE. PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT 5L 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 t0 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. p TYPE OF SERVICE REQUESTED: Y � �jV � COMMENTS: AMY ✓o ?®1.9 �q R M� ACCEPTED BY: EMPLOYEE#: 3 DATE: ASSIGNED TO: EMPLOYEE#: DATE: G Date Service Completed (if already Completed): SERVICE CODE: 3 P!E: i O Fee Amount: Amount Pai �SL�0 Payment Date 511611 Payment Type Invoice# Check# Recei ed By: E H D 48-02-025 SR FORM(Golden Rod) 07/17108 �� 2 >3 6 G.