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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property BUSINESS NAME FACILITY ID # SERVICE REQUEST # HOME or MAILING ADDRESS I j v I FAX # ) CITY ZIP 0/ �1 / STATE CA i OWNER / OPERATO WQO� \v CHECK If BILLING ADDRESS FACILITY NAME DATE: .26 1 t? tFI' SITE ADDRESSYu � CODE: 1 _3SERVICE P / Ei: blo I 0eet 5 um er Direction Payment Date tree[ ame Invoice # Zi ode OME Or AILING ADDRESS (If Different fr m Sit dres;)� Street Number Street Name CITYVj \ �/ v y STATE ZIP nj -{-- (') J PHONE#1 EXT. (2,0 1370— V `� APN # LAND USE APPLICATION # PHONE ill EXT. ( ) BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR \CHECK If BILLING ADDRESS �11 BUSINESS NAME P NE EXT. HOME or MAILING ADDRESS I j v I FAX # ) CITY ZIP 0/ �1 / STATE CA i 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, STATE ERA APPLICANT'S SIGNATURE: DATE: 1 PROPERTY/ BUSINESS OWNER ❑ OPERATOR / MANAGER THER AUTHORIZED AGENT ❑ /f 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 t0 me or my representative. TYPE OF SERVICE REQUESTED: l� Y �"�tA f�D I= �4-11FIV7- COMMENTS: C'eJdlr�rl� gin�y �rr7 J 1vj'® �'E� L 6 2019 -SAN ENVOAQ IN 7 HEALTH AL ACCEPTED BY: j /' �� EMPLOYEE #: DATE: /9 i� ASSIGNED TO: �avi '% EMPLOYEE #: Q(� U DATE: .26 1 t? tFI' Date Service Completed (if already completed): CODE: 1 _3SERVICE P / Ei: blo I Fee Amount: (,�'(X: Amount Paid= L - i :; �, Payment Date Payment Type ✓ Invoice # Check # �- c <_, ., Received By: C (� EHD 48-02-025 SR FORM (Golden Rod) 07/17/08