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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST a oq gS-3 -76 X17 Type of Business or Property FACILITY ID# SERVICE REQUEST# (�Rffl0`4C19 idolkal F OWNER/ OPERATOR A/AI CHECK if BILLING ADDRESS c� FACILITY NAME gelKSITE ADDRESS �G` ) I+`l I �I'� S`F�sr' ./� l ��/� Street Number Direction Street Name Citt^�� Zi Code HOME or MAILING ADDRESS (if Different from Site Address) Sa n L� Street Number Street Name CITY STATE ZIP PHONE#1 EXT• APN# LAND USE APPLICATION# PHONE#2 EXT. BOS DISTRICT LOCATION CODE ( ) q CONTRACTOR/ SERVICE REQUESTOR REQUESTOR A( ure erg �( l CHECK If BILLING ADDRESS❑ BUSINESS NAME PHONE#_ EXT. HOME or MAILING ADDRESS1 FAX# Dn� 1 I,Cc r t ( ) oe- CITY , n STATE zip c 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 I have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes,Standar s,STATE and FEDERAL laws. At u,SIGNATURE: ' 4 , u k C c 44-7�t DATE: PROPERTY/BUSINESS OWNER 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 provided to me or my representative. TYPE OF SERVICE REQUESTED: aelp in C/e1VW,)11r setbtickS for r, re le4(,e en� s ep312 Sys-l-em COMMENTS: 3 becJ10OW I/JiYefuIle R-1�5 e,0, Ilnes 6i"d 3-36 P; or -the e�vlvoie71 ' 1,., c1a eAreG• Cvrreof ttir►k PCO;ply v11G/es Douse. p„ Fobill Wq� 'gfr"k to �►-J or y �vFo OCT Z 8 ?020 AN 40AQUIN C ACCEPTED BY: �T� EMPLOYEE#: DATE: ASSIGNED TO: �j„� EMPLOYEE#: DATE: I Old 8 aQQlb Date Service Completed (if already completed): SERVICE CODE: Fee Amount: j S oZ AmOUnt Paid �GJ a Payment Date ' 2� Payment Type 1.1 Invoice# Check# 3 Q �- Received By: EHD 48-02-025 SR FORM(Golden Rod) REVISED 11/17/2003