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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property CHECK if BILLING ADDRESS BUSINESS NAME �- FACILITY ID # SERVICE REQUEST # HOME Or MAILING ADDRESSy7� 1 Tf-0i�P-� , N ,( Ltry FAX# ( ) CITYIpL A �/> > A 1 1 L6 STATE ZIP �_ / r OWNER/ OPERATOR EMPLOYEE #: ❑ JA j0tyVANG,— EMPLOYEE #: CHECK if BILLING ADDRESS FACILITY AME L a /N FII Vu E1=67T PIE: , Fee Amount: — SITE ADDRESS _ F Ctq F� ` - LN C1 p (' JCt r f L - o D 1 7-5 240 tel' Street Number Direction Street Name city(ZI Code HOME or MAILING ADDRESS (If Different from Site Address) yZ2;2. I v Street Number Street Name CITY CIC �" roN STATE CA ZIP q �2cvw PHONE #1 ExT. APN # LAND USE APPLICATION # PHONE #2 ExT" BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR p� r4 if � riril" w ti 1 `�F CHECK if BILLING ADDRESS BUSINESS NAME �- 04VlC `10' J hEyi�",R PHONE# I ExT. r � y � / HOME Or MAILING ADDRESSy7� 1 Tf-0i�P-� , N ,( Ltry FAX# ( ) CITYIpL A �/> > A 1 1 L6 STATE ZIP �_ / r 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 and FEDERAL laws. APPLICANT'S SIGNATURE: - DATE: 2-26 PROPERTY/ BUSINESS OWNER❑ BATOR /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 environ rr� l/slte assessment information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available atA e time it is provided to me or my representative. TYPE OF SERVICE REQUESTED: !j" rA ilrr`" P1619 9 COMMENTS: C O V V�Z--r E X n �i7r' A V 2 ArTr 04VlC `10' J hEyi�",R N��'yoo yoF''9h'1 �ry T ACCEPTED BY: r�ttiG� EMPLOYEE #: DATE: ASSIGNED TO: EMPLOYEE #: DATE: Date Service Completed (if alre dy completed): SERVICE CODE: f' ?�� PIE: , Fee Amount: — Amount Paid �L��, �� Payment Date 26 Payment Type Invoice # Check # Receiv By: EHD 48-02-025 SR FORM (Golden Rod) REVISED 11/17/2003