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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property REQUESTORCHECK if BILLING ADDRESS❑ FACILITY ID # PHONE # ExT. BUSINESS %TAME oz - �s SERVICE REQUEST HOME or MAILING ADDRESS FAX # ox 3 ( V I/`J :< 5 / �F-1V A L EMPLOYEE #: DATE: ,�17 �p �T ASSIGNED TO: 467 EMPLOYEE #: �� DATE: OWNER / OPERATOR PIE: (]Q% CHECK if BILLING ADDRESS GlSa o F - ✓t �0 FACILITY NAME Invoice # Check # SITE ADDRESS 33 g8 /L� 20f1%�NTE( gs 3 37 Street Number Direction Street Name Ci Zi Code HOME or MAILING ADDRESS (If Different from Site Address) S� QD �,cl.s r F� ROA D Street Numher Street Name CITY � 714 /v ��i GI� /� . / , / STATE ZIP SL3 7 PHONE #1 ExT. APN # LAND USE APPLICATION # (dog) 67Oo2- (a-OSO-0A PHONE #2 ExT. [66sDiSTRICT S LocanQN CODE Cn1VTR ACTOR / SERVICE REOUESTOR 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 1 have prepared thi lication and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, Standar s, TATE and FEDE i, laws. APPLICANT'S SIGNATURE: 1 DATE: 8 LT 0 PROPERTY/ BPSINF,SS OwNE�m OPERATOR / 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 available and at the same time it is ..:A At men v rr>nrac.+ntntive TYPE OF SERVICE REQUESTED: SO/L 5-" TAD14-t N/ 7-)eATilr L -UA D REQUESTORCHECK if BILLING ADDRESS❑ ON G F-5NF_ E PHONE # ExT. BUSINESS %TAME oz - �s E r 0 m..5 U L HOME or MAILING ADDRESS FAX # ox 3 ( CITY STATE ZIP LOG 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 1 have prepared thi lication and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, Standar s, TATE and FEDE i, laws. APPLICANT'S SIGNATURE: 1 DATE: 8 LT 0 PROPERTY/ BPSINF,SS OwNE�m OPERATOR / 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 available and at the same time it is ..:A At men v rr>nrac.+ntntive TYPE OF SERVICE REQUESTED: SO/L 5-" TAD14-t N/ 7-)eATilr L -UA D <;)eV COMMENTS: (� EIVED AUG 2 7 2020 SAN J0gENVQU1N COUNN I RONMENTq HEALT ACCEPTED BY: �� L. EMPLOYEE #: DATE: ,�17 �p �T ASSIGNED TO: 467 EMPLOYEE #: �� DATE: Date Service Completed (if already Completed): SERVICE CODE: ri PIE: (]Q% Fee Amount: Amount Paid Payment Date �0 Payment Type Invoice # Check # Received By: EHD 48-02-025 SR FORM (Golden Rod) REVISED 11/17/2003