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NAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT r SERVICE REQUEST Type of Business or Property w BUSINESS NAME FACILITY ID # HOME Or MAILING ADDRESS SERVICE REQUEST # CITY STATE ZIP ACCEPTED BY: EMPLOYEE #: (L DATE: X919 ASSIGNED TO: EMPLOYEE #: � DATE: CDC) QqW0 OWNER I OPERATOR "�" R s I �� r: �� / , t%� �I (� Ce ►e P a ,'-Y T i c l" CHECK if BILLING ADDRESS FACILITY NAME 1 rV JJ Payment Date i8�lty�� — 72711 SITE ADDRESS 16Gv p Invoice # T Street Number Direction Street Name city Zip Code HOME or MAILING ADDRESS (if Different fromp Site Address) Is/ S4 () ) I -s 1, � � � 1�>] Street Number Street Name CITY S'�Z1C�c� STATE C ZIP c� PHONE #1 EXT. APN # LAND USE APPLICATION # (?�) 22— S� oZ PHONE #2 EXT. ( ) BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR �-U -'� J, , ^/A CHECK if BILLING ADDRESS Vi� (� v t"\ BUSINESS NAME PHONE # ExT. HOME Or MAILING ADDRESS FAX # CITY STATE ZIP 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, S TE and FEDE aws. ,+ Q APPLICANT'S SIGNATURE: DATE: / ^C�y PROPERTY/ BUSINESS OWNER ❑ PERATOR / MANAGER ❑ OTHER AUTHORIZED AGENT ❑ If APPLICANT is not the BaLINGPARTY, 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: UST 6 - COMMENTS: Ak V ©'^`, 6-J '3qN J 6 200 N�<T�9 Nl � CO H M ACCEPTED BY: EMPLOYEE #: (L DATE: X919 ASSIGNED TO: EMPLOYEE #: � DATE: Date Service Completed (if already Completed): SERVICE CODE: r P 1 E: —Zlky Fee Amount: ''� Amount Paid GIg . D U Payment Date i8�lty�� — 72711 Payment Type Invoice # Check # p Received By: EHD 48-02-025 ,SR FORM (Golden Rod) REVISED 11/17/2003