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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH L ..PARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID # SERVICE REQUEST # i 12- 0(.171()0 VI\ \F OWNER / OPERATOR f5 •-.1.:\ i .,-D ri2 k---, c_7c7.--> 1/< ----?-7- 1-..;`-,. V, o p ;--- CHECK if BILLING ADDRESS • -----F ‘ IS FACILITY NAME c---E---71—\----t SITE ADDRESS 6 5-532 Street Number Direction 5k 5 .../k) 620L -9 Street Name N. City Zip Code HOME Or MAILING ADDRESS (If Different from Site Address) Street Number Street Name CITY STATE ZIP PHONE #1 EXT. (65 0) 7 Z-2_ 06 g 0 APN # LAND USE APPLICATION # PHONE #2 EXT. (Zeci ) 5‘A 7 4(q 6( BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR __, D .. N. \.- v 1-----_,— -3>Cre. CHECK if BILLING ADDRESS ' - 6-; .e---C3-9—',:_---‘; LA Nit ''' BUSINESS NAME.,---, ' \ E—\—C\-- t.— \--ot>112- 1 5G-"--—f---- PHONE # (650 ) -7 0 2- EXT. 06;50 HOME or MAILING ADDRESS 55'32_ `..', , kJ 6-7 o Lt? FAX if CITY • 5 (—A STATE ZIP '9536 W 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. - APPLICANT'S SIGNATUR____ PROPERTY! BUSINESS OWNER El OPERATOR / MANAGER El OTHER AUTHORIZED AUTHORIZED AGENT El If APPLICANT is not the BILLING PARTY proof of authorization to sign is required Title AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the pwner 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 aatessment information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time 41144fAtilecktp.4.-ne or my representative. - TYPE OF OF SERVICE REQUESTED: VI; (A ri GI -Jai r- JuL 0 h COMMENTS: - 2017 SAN 1 _ -0AQui lv UNT'y ", t NVIRoNNTAL EALTH DEr.7,, r-bkRTmEN7 ACCEPTED BY: -- emu n Det EMPLOYEE It: DATE: -11(e I 17 ASSIGNED TO' ?E.DP-1-1714 EMPLOYEE #: DATE: -7 I if I? Date Service Completed (if already completed): SERVICE CODE: C.; ) -1 P/E: \A)) Fee Amount: 4 -_, (4) . o 0 Amount Paid Payment Date Payment Type Invoice # Check # Received By: DATE: EHD 48-02-025 SR FORM (Golden Rod) 07/17/08