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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Pro rty FACILITY ID# �(SERVICE REQUEST# t�is'"rt OWNER I OPERATOR CHECK If BILLING ADDRESS FACIUTYNAME SITE ADDRESS 13�3 L�Ner✓ �/ aCyhgrClJ Street Number Direction Street Name CI Zip Code HOME or MAILING ADDRESS (If Different from Site Address) Y e ?„ Street Number Street Name CRY STATE zip D PHONE#1 ExT• APN# LAND USE APPLICATION# Uf (ZZ)tq) 2 2 i CPLP2 3 2 SAN iDAQU PHONE#2 ExT• BOS DISTRICT II:pID NTq Ty { 1 GI gR24 NT CONTRACTOR/ SERVICE REQUESTOR ReQUESTOR ('-/J2pt-j e— 0AViaM;e CHECK If BILLING ADDRESS BUSINESS NAME (f �S r�u L�t � PNONE# Ex-,, 22,/ Gr�2 3 HOME or MAILING ADDRESS FAx# CITY �<�G¢,�L�� STATE4;yc,. zip �S.2J ZQ 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 FEDFRAL laws. i t APPLICANT'S SIGNATURE: L DA'rE: f �� 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 environmentaUsite 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. TYPE OF SERVICE REQUESTED: i N.`SPI Gr{61—J O 1SC V�� L/J tai }-IAC 'Q� � �I L -T�t-j — COMMENTS: Vel, C�nnz6flin bl eXlsfirl Sf T!C s str� - , )11 " „/I y fiv cl, bt. ,Id ��t:1c(I jl�n fo g�. bu,1 I gp-�gold�� ACCEPTED BY: _ G/L- EMPLOYEE#: DATE: S7 Z0,7AO ASSIGNED TO: S!` EMPLOYEE#: DATE: S'l7 Z D Z 0 Date Service Completed (if already completed): SERVICE CODE: !/E: t/d0a Fee Amount: Amount Paid /s?, 9D Payment Date 7 Payment Type Vi Invoice# Check# /03.2-7,57-/1_3 Received 13y: EHD 48-02-025 SR FORM(Golden Rod) REVISED 11117/2003