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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID # Loo / (J SERVICE REQUEST # �DoncAS 5h (D �— CITY T E ZIP G/ 5ROOB 1-707 OWNER/ OPERATOR S CHECK if BILLING ADDRESS Y'�)Cynctv'kA (' FACILITY NAME . FDonls SITE ADDRESS I 1664 E "larch (n #-3 S%OC.`C-t ova cis2l0 IC611 Number Direction Street Name City Zi Code HOME or MAILING ADDRESS (if Different from Site Address) Street Number Street Name CITY STATE ZIP PHONE#1 EXT APN# LAND USE APPLICATION# PHONE #2 Ear. BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR / L CHECK If BILLING ADDRESS REQUESTOR —Da/ l BUSINESS NAME ^� A Loo / (J PH E # Ai// ExT' G�(Z/ HOME or MAI ING DDREB/S' FAX# CITY T E ZIP G/ BILLING ACKNOWLEDGEMENT: 1, 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. 1 also certify that 1 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 IT FEDERAL la �/ APPLICANT'S SIGNATURE: DATE:OZ %C7 PROPERTY/ BUSINESS OWNER El OPERATOR/ MANAGER ❑ OTHERAUTHORIZEDAGENTO If APPLICANT is not the BILLING PARTY proof of authorization to sign is required Title AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, 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/sitz assessment information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPAR"rMENT as Soon as It is available and at the Same time it is provided to me or my representative. Ate_ TYPE OF SERVICE REQUESTED: COMMENTS: I A)PO'9(/6w w-) i FFB 9 2020 ACCEPTED BY: 1• f to Osuo EMPLOYEE #: DATE: ��•! �A�/s ASSIGNED TO: \RA Vv 't... EMPLOYEE #: DATE: Date Service Completed (If already completed): SERVICE CODE: S 2 PIE: f Fee Amount: _ Amount Paid—�UGTO'Payment Date 2 11 202-0 Payment Type pn Invoice # I Check # Received By: 111 m EHD 48-02-025 (U• 19�M REVISED 11/17/2003 ✓ IMMU32- SR FORM (Golden Rod)