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CALL (209) 953-7697 FOR INSPECTION. 48 HOUR NOTICE REQUIRED. SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST ess or Property CHECK If BILLING ADDRESS FACILITY 10 # COMMENTS: PeP6nt,e0c?Il'i YY+a6i I h'01P- I•e -usin( scf J 1 SERVICE REQUEST #C V1 PHONE# EXT. tj &EQ z 1p Cae#e1r►^1rse 0;lele prctct�d 5z 0;J �g <;s r If ESV FAx# '1 . _. J OWNER OPERATOR CITY STATE CA ZIP CM—Lb ACCEPTEDBY: �_ �._ CHECK if BILLING ADDRESS T ASSIGNED TO: EMPLOYEE#: FAC]LITY NAME r Date Service Completed cif already completed}: SITEADDRESS SERVICE Cooe: 04- P i E: '-D Fee Amount: Jr � f r Payment Date �1142-1 I LJ J rf Stmet Number Directlon t' 1 t. 1 ei Name Not l Zip Code HOME Or MAILING ADDRESS (If Different from Site Address) Street Number Street No CITY STATE ZIP PHONE#1 EXT. APN # LAND USE APPLICATION # PHONE #2 Ea. �{�C� SOS DISTRICT LOCATION CODE r. ( /�� } CONTRACTOR 1 SERVICE REQUESTOR REQUESTOR CHECK If BILLING ADDRESS J COMMENTS: PeP6nt,e0c?Il'i YY+a6i I h'01P- I•e -usin( scf J 1 BUSINESSNAME V1 PHONE# EXT. tj &EQ z 1p Cae#e1r►^1rse 0;lele prctct�d r_ -y _ HOME or MAILING ADDRESS If ESV FAx# '1 . _. C t } CITY STATE CA ZIP CM—Lb 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 al SAN JOAQUIN COUNTY Ordinance Codes, .Standards, STATE and FEDERAL laws. APPLICANT'S SIGNATURE:L_ , I �—�. DATE: PROPERTY BUSINESS OWNER OPrRATOR / MANAGER ❑ OTHER AUTHORIZE) AGENT ❑ If APPLICANT is not Lute BILLING PAR7•Y, proof of authorization to sigh is required Tfrle 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 environmenta(Isite assessment information to the SAN JOAQUIN COUNTY ENVIRONMENTAL 14EALTH DEPARTMENT as Soon as it is available and at the salve time it is provided to me or my representative. TYPE OF SERVICE REQUESTED: Yelp 0tt=,JVfMlne- I,(c-YID1.1 lar neva )e6th r1�1Q Cjr new m' c 111-11 e. COMMENTS: PeP6nt,e0c?Il'i YY+a6i I h'01P- I•e -usin( scf J 1 S•y5 frM Qr a,�k I st'Ff1L �pf'►ls� V1 d 6P,:'/1W0.' f'P5iC1f-1 LP NCO Y-4bJt borne Is � �aeC�r o�rn� �I r1FPC.! �` 6f 1F� cv, 10C CAr� 6e tj &EQ z 1p Cae#e1r►^1rse 0;lele prctct�d ��j0 L) Se 3oiDio ofr►n6e fat to f"Ict ln��.�ti��1. If ESV 24 �1 QO/V CO ACCEPTEDBY: �_ �._ EMPLOYEE#: DATE: T ASSIGNED TO: EMPLOYEE#: DATE: q ! c� r Date Service Completed cif already completed}: SERVICE Cooe: 04- P i E: '-D Fee Amount: Amount Paid f r Payment Date �1142-1 I LJ Payment TypeInvoice # = �� Received By: Not EHD 48-02-025 SR FORM (Golden Rod) REVISED 11/17/2003