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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID # PHONE# E%T. ) 6-3 S Z 1 SERVICEJQUEST # FAX# CITY /_ v J s T ZIP �Azi Q�T 08 S �8272� OWNER / OPERATOR 1 ' v Ti yT"/� CHECK If BILLING ADDRESS ?O r � /f/ / !�i FACILITY NAME( SITEADDRESS ACCEPTED BY:Taw EMPLOYEE M �OCIt I✓:J OO Stmet Number Dlrectlo treet Na e Date Service Completed (if already completed): YS2y ZI Code HOME or MAILING ADDRESS (If Different from Site Address) tl,{ �-/ a13 0 CL✓ Q Street Number Amount Paid Street Name CITYq o d STATE ZIP 9_5--)--"12_ PHONE#1 ExT. APN# LAND USE APPLICATION# ryes �';2-z-'/ PHONEW2 EXT. BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR = CHECK If BILLING ADDRESS E] BUSINESS NA E PHONE# E%T. ) 6-3 S Z 1 HOME or MAILING ADDRESS l 0J 0ri'� FAX# CITY /_ v J s T 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 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 and FEDERAL laws. //�� // APPLICANT'S SIGNATURE: gam` DATE:�(J / �� PROPERTY/ BUSINESS OWNER❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT❑ /fAPPLICANT 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 t0 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: O cons u 0 COMMENTS: �Azi Q�T 08 sgN,lo 2020 &HVIAQUIN HEALTH SZ, A ��A'>Y ACCEPTED BY:Taw EMPLOYEE M DATE: A1210 ASSIGNED TO: EMPLOYEE M DATE: j 0 tP/ Date Service Completed (if already completed): SERVICECODE: tl,{ �-/ Fee Amount• Amount Paid I r� Payment Date 1v 20 Payment Type v Invoice # Check # Received By: EHD 48-02-025 SR FORM (Golden Rod) REVISED 11/17/2003