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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID# SERVICE REQUEST# I u L L,1!2 +irUJ'(- ::I FACULLL 'f2)-(�-00-29CJC� � OWNER/OPERATOR ` ( k--,A, ( e `^ ^C CHECK If BILLING ADDRESS ILL rA FACILITY NAME cc G 1 ` lJd V / 3� / ��ADDRESS � � (. �/✓7^'y �d C"kfd VI C4 y S Z CEJ ... vlJ Street Number Direction Gr DI nJ Street Name CI ZipCode HOME Or MAILING ADDRE 5 (ITisDifferent from SSite Address U52 . WI� wL 7 Street Number Street Name CITY / C / a STATE ZIP PHONE#1v(v_ fir' APNJ# LAND USE APPLICATION# (toy, no"Lg ' 71��0 1 t��J)dO-lD PHONE#2 ExT, SOS DISTRI 36T LOCATION CODE X13 �so2 -1 CONTRACTOR/ SERVICE REQUESTOR REQUESTORt c CHECK If BILLING ADDRES BUSINESS NAME \ PHONE# ExT. O e I i d us z4 -7/3 HOME or MAILING ADDRESS FAX# GJr a rvl.y ( , ) CITY ?�ck1, Y" ?— C F— STATE 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 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. I _ APPLICANT'S SIGNATURE: �� .C�� l�AC DATE: PROPERTY/BUSINESS OWNEWE OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ If APPLICANT IS not the BILLING PARTY,Proof Of authorization to sign IS required Tile 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. p � TYPE OF SERVICE REQUESTED: a ( V e I -2 �G C�y1 PAYMEW COMMENTS: IMICE )wI5 10 2018 SM JOAQUIN COUN BY: /T EMPLOYEE#: DATE: ASSIGNED TO EMPLOYEE#: DATE: Date Service Completed (if already completed): SERVICE CODE: i PIE: J o3 Fee Amount: 1��- Amount Paid Payment Date 8/fib Payment TypeCk Invoice# Check# -Received By: U� EHD 48-02-025 SR FORM(Golden Rod) 07/17/08