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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Typi f Business or Property FACILITY ID # SERVICE REQUEST # dill Kil, � � Olt FA Doo �701 SV OWN R / OPERATOR �• 6LO � t ( tel jc { � CHECK If BILLING ADDRESS El FACIL NAME Powf (a M N KE7 SITE DRESSOP �/h t3tnet Number Dlrectlon at Nah HDM or MAILING ADDRESS (If Different from Site Address) Z Code S� (�(� N • ��1� - T � 0 P>L VC) Street Numberf1Cj CITY STATE CA ZIP PHON 91 T• APN # J AND USE APPLICATION # Fill t1 1 (0 \ - 5421 PHO ft2 ExT. OS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR 4uSI 5T 1� ' \ _ ' `� HECKIf BILLING ADDRESS ss NAME � ��rl�' Pl e # EXT , J oiry 3b L 1 rL} Homa or MAILING ADDRESSt CITY �r�{ � ST FAX # _i ,� �: "I l it v STATE ZIP C � • LL ING 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 activiy will be billed to me or my business as identified on this form , als certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN Com Ty Ordinance Codes, Standards, STATE and FED laws , APP (CANT 'S SIGNATURE : DATE : PROF z. RTY / BUSINESS OWNER ❑ OPERATOR / MANAGER ❑ OTHER AUTHORIZED AGENT ❑ If APPLICANT Is not the BILLING PARTY, proof of authorization to sign is required Title AUTI IORIZATION TO RELEASE INFORMATION : When applicable , I , the owner or operator of the property located at the above site ddress , 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 a5 it is available and at the Same time it Is provided t0 me Or my r resentative . TYPE F SERVICE REQUESTED : t✓[ S �� 'ZJ .� + w COMM TS : ` ry G� V�h •n �� 2020 Q�� Alf �E ENVIRONMENTAL HEALF1-gA� JA� � DEPARTMENT ��oT 0 A'f 0a ol 'ry AcCE RTED BY: EpE i t S • 2 ��Q�/—Z.�� EMPLOYEE #: DATE : 2 ASST ED TO : �� /� /� IEMPLOYEE # : DATE : t/V ! 29 20 Date ervice Completed (if already completed) : SERVICE CODE : ` l �' P / E : 2 - -+ L� Fee ount: � c� Amount Pal 15 0 D� Payment Date o 3l � Pay nt Type /14-1 � Invoice # Check # .2g� Received By: 6 ll EHD -02-025 07/ 17 ( 8 SR FORM (Golden Rod )