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PR 05360`ID SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID# SERVICE REQUEST# F/k 001 q� D `�1� 00S�� OWNER'/-OPE OR ^ !A n J V` T Cr1�I S p)0 e Am— FACILITY CHECK If BILLING ADDRESSO I V V NAME Lm O !n � SITE ADDRESS 1 '31z. vIs Sfte&Number I Direction �� ree (a J "' 'City 1 i Cotla HOME or MAILING ADDRESS (If Different from Site Address) �3�� V': CCA(V1 r-7 ) . --V Street Number Slreal Nama / ` v CITY 0A'�, ,^wv' STATE OA ZIP /�rJ� PHONE#1 EXT. APN# LAND USE APPLICATION # vt PHONE#2 EXT. BOIS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR WREQUESTOR,. _ I ,�p ,r 51 1 ` i7�t Q d� CHECK If BILLING ADDRESS BUSINESS NAME r v O�V� n..7 �Y 1'C�2, PWA �I �. -Z J -^ HOME or MAILING ADDRESS ,''fy�.� G /Xe ,^ A I _ y FA%# �i ✓V \i - , 1.uL,V�. ]�V/(� 1 ) n' CITY A�j STATE ZIP 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. 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 FEDERAL laws. �l APPL'ICANT'S SIGNATURE: y,(p� �DnTe:"'S 1 -0 t PROPERTY/BUSINESS OWNER❑ OPE TOR/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 environmental/site assessment Information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it Is avail~fiMTme time it is provided to me or my representative. RECEIVED TYPE OF SERVICE REQUESTED: COMMENTS: OCT 0 5 2020 A 1n ' p SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT ACCEPTED BY: Y Y IOAD 0 0 EMPLOYEE#: DATE: Ill^ ASSIGNED TO: �A ' r1 EMPLOYEE#: DATE: I Date Service Completed (If already completed): SERVICE CODE: O� PI E: Fee Amount: _ Amount Paid Payment Date Payment Type Invoice# Check# Received Byk t EHD 48-02-025 SR FORM(Golden Rod) REVISED 11/17/2003