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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTDEPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID # SERVICE REQUEST # C-7 A4S S }moi a r, % 000(e 439' SO46gn l3 OWNER/ OPERATOR HOME or MAILING ADDRESS 1 53 S" lcJt47 Lu 4 n, 7!>2t ve /l �I, (� (L U LCFACILITY CHECK If BILLING ADDRESS NAME SLitf (4 CC7 7� r LL_I f SITE ADDRESS 1`103 COu Irl / _ _ C� 43S /� ] Z� cxnno 1')cls T v Street Number Direction DATE: Street Name citv Zip Code HOME or MAILING ADDRESS (If Different from Site Address) n 5 -�')EI L/ 4L' - SERVICE CODE: (% PIE: - 3 De Street Number Street Street Name CITY c ( s , STATE ZIP rK 7-7 v 7 5 PHONE #t EXT. APN # Invoice # LAND USE APPLICATION # (4),�) 9IF3-Z.oeZ— PHONE #T EXT. ( ) BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR (D49-124 CHECK if BILLING ADDRESS El /�J t �L COMMENTS: BUSINESS NAMEPHONE# E-(-, 4-eC6�-,-kac46rJ' ExT. 1 ) 11 6237 HOME or MAILING ADDRESS 1 53 S" lcJt47 Lu 4 n, 7!>2t ve IEC 72005 FAX # / (Zo% ) V631f2— CITYS-?,6C (C-Ot.� STATE &A ZIP �SZ 0 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 preparedthis ap I ation and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, Standards, TA E and FEDERAL laws. -11'APPLICANT'S SIGNATURE: BDATE: PROPERTY / BUSINESS OWNER ❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT ❑ 4IL()[co— 4- 4v If APPLICANT is not the BILLING PART): 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 to me or my representative. TYPE OF SERVICE REQUESTED: COMMENTS: IEC 72005 ENVIRONMENT HEALTH RERMITISERVICES ACCEPTED BY: EMPLOYEE#: J ? go DATE: ASSIGNED TO: %� / EMPLOYEE #: _ D� n4TE: 12 /d' `O, - Date Service Completed (if already completed): SERVICE CODE: (% PIE: - 3 De Fee Amount: '1 V0 Amount Paid "' ";` Payment Date L Payment Type Invoice # Check # __a Received By: