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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID# SERVICE REQUEST# OWNER/OP��7 ATOR r g �� I CHECK If BILLING ADDRESi FACILITY NAME Pvv SITE ADDRESS � J��nC TIG Vim- AA 4"'1 pr01 3 Iv I I Street Number I Direction Street Name C ity Zi Code HOME Or MAILING ADDRESS (If Different from Site Address) n Street Number Street Name /� CITY STATE ZIP IV r PHONE#1 ExT APN# LAND USE APPLICATION# •\c` 0 c ) - APR 1 g 119 PHONE#2 EXT. BOS DISTRICT L CONTRACTOR/ SERVICE REQUESTOR I;EpATMEn►r REQUESTOR n I V) CHECK if BILLING ADDRESS❑ .1.. S BUSINESS NAME PHONE# EXT. S�- y vtjc �r K� zfq s 3 2 Z HOME`or—M]A�ILINNGG ADD&E S `� I (1��` FAX# ) S ✓ � ��GWS TGA F�v 1✓Q ( ) CITYl� STATE ZIP BILLING ACKNO LEDGEMENT: 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 this form. I also certify that I have prepared this applic n-a that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, Standar TAT L laws. / c APPLICANT'S SIGNATURE: DATE: PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ If APPLICANT IS not the BILLING PARTY,proof of authorization to sign is required Tide 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: COMMENTS: �O , -io /r-/ A I&_J .r&I v EC.—GL V / fes T� Com) -S-r - .r'6A� . � po1r�/ r- -It 0/ r�D�� CEJ 1-�CN ACCEPTED BY: EMPLOYEE#: DATE: ASSIGNED TO: EMPLOYEE#: DATE: Date Service Completed (if already completed): SERVICE CODE: e P/E: Fee Amount: Amount Pai /�2 Ul Payment Date �s Payment Type Invoice# ` 1 _DCheck# 15� Received By: -76EHD 48-02-025 � �� _ SR FORM( olden Rod)