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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property L 0 v /^ y ma / �� e (f (� FACILITY ID # BUSINESS NAME ERVICE REQUEST # PHONE# EXT, :L rtPGtr 1pt� 5eF114# 5kSf� y' " 1 C }�G� prafet� is tWe 0 (9 OWNER/ OPERATO HOME or MAILING ADDRESS / l P }o E iVEO El iR 4-�J I/, 'i )� n 1 �� R e !/�/ CHECK if BILLING ADDRESS FACILITY NAME SITE ADDRESS jGC'n�'>C'15t SP�oY'C,� 5 SAN %/OAQUIN n r �(J rnl ACCEPTED BY: �.i� / GI EMPLOYEE Street Number Direction Street Name City Zip Code HOME or MAILING ADDRESS (If Different from Site Address) ASSIGNED TO: l _ / Street Number Date Service Completed Street Name CITY SERVICE CODE: , P / E: ya L) � STATE ZIP Amount Paid 41, ✓ atm PHONE #'l ExT• APN # LAND USE APPLICATION # (k4(�P �103-L111 Check # p I��iJI PHONE #2 ExT•BOS DISTRICT LOCATION CODE CONTRACTOR /SERVICE REQUESTOR REQUESTOR L 0 v /^ y ma / �� e (f (� CHECK if BILLING ADDRESS BUSINESS NAME COMMENTS: To V e �) tl% PHONE# EXT, f0'O 11 Cr rtPGtr 1pt� 5eF114# 5kSf� y' " 1 C }�G� prafet� is tWe Putzels. Ur public , �c:�c�r. beeJtoom HOME or MAILING ADDRESS / l P }o E iVEO FAX # 7 �C P lS, CITY LSTATE ZIP r 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 cert ify that I have prepared this application and that the work to be pe ed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, Standards, STATE and FEDERAL law APPLICANT'S SIGNATURE: �` DATE: ll ZZ, 20 PROPERTY / BUSINESS OWNER❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT 1 W 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 aLove site address, hereby authorize the release of any and all results, geotechnical data Al 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: I n 1 )de f �l REVISED EHD 48-02-025 („ `/ 11/17/2003 SR FORM (Golden Rod) COMMENTS: To V e �) tl% t r�Gl I tie fe IS er"foll f0'O 11 Cr rtPGtr 1pt� 5eF114# 5kSf� y' " 1 C }�G� prafet� is tWe Putzels. Ur public , �c:�c�r. beeJtoom . iNeecJs a }o E iVEO )-e'o& )nc of 1 he ele �Va�/Nn3 I•, P lS, fV V U 0 2020 SAN %/OAQUIN rnl ACCEPTED BY: �.i� / GI EMPLOYEE #: %TH Q T ASSIGNED TO: EMPLOYEE #: DATE: I ( A L76,C) Date Service Completed (if already completed): SERVICE CODE: , P / E: ya L) � Fee Amount: f tSa Amount Paid 41, ✓ atm Payment Date �I 3 2O Payment Type Invoice # Check # Received By: EHD 48-02-025 („ `/ 11/17/2003 SR FORM (Golden Rod)