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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property FACILITY Ip# SERVICE REQUEST# CSucili `� 'o�� 3v_7 OWNER 1 OPERATOR Og.... k �� CHECK If BILLING ADDRESS FAcam NAME 1�rl 1�� - i SITE ADDRESS - l Pad(U RV C) .�tc►C��l 9520 Street Number Direction Street Name 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#. Exr• BOS DISTRICT LOCATION CODE CONTRACTOR/ SERVICE REQUESTOR REQUESTOR CHECK If BILLING M. ADDRESS Bt1sINESS,NAME \ _ PHONE �2�EXT• . HoIIAE Or MAILING ADDRESSFAX# t lJl 2-5 i55 l -, ( 2c 1) z- C 13�2-- CITY STATE QP ZIP BILLING:-ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acldiowledge 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-L have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance.Codes,Standards,STATE and FEDERAL laws. n,� APPLICANT'S SIGNATURE: DATE: tyMC iY�}t ��).V• PROPERTY/BUSINESS OWNER 0 OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT 1A IfAPPLIGANT.is not the BILLINGPARTE 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 _ _, r` .,&bogie slte address,-hereby_authorize tie release ofany and all results' geotechnical data an environmental/site assessment Information_:Io the SAN JOCOUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is _ .provided to me or my representative. _. -_-_ A. TYPEUF,SERVICEREQUESTED: — COMMENTS ;ice `.°' IEice NVIR�N�ESERV1Cc , CEPTEDBY.`' EMPLOYEE#: DATE: � Cr SSI�NEQ TO --EMPLOYEE-#: DATE: `Date ServICe Completed '(if already Completed): SERVICE CODE: P)E: a.3 Q Fee Amount : ;?� Amount Paid Payment Date F -Payment Type. �� Invoice# Check# , C) + Received By: __ ;