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SAN JOAQUI `T ;OUNTY ENVIRONMENTAL HEALT-- DEPARTMENT SERVICE REQUEST Type of Business at Property &JY"-'Y+vU1 U 6 FACILITY ID # �) d SERVICE REQUEST # l�°� lavlo, 30 OWNER/ PERATOR ' CT. CHECK if BILLING ADDRESS FACILITY NA W ACCEPTED BY: ti SITE /ACoR'ES`S' ��I NST �–L r Street Number Direction ASSIGNED TO: , Q Street Name f1 t1 C �/i Ci � "16 i Code HOME or WALING ADDRESS (If Different from Site Address) ty Street Number Street Name CITY STATE ZIP PHONE#1 /� EXT' APN# Payment Type LAND USE APPLICATION PHONE#2 EXT. Received By: GfZs— BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR '^ ,�� (H(A J CHECK if BILLING ADDRESS M=AAELBUSINESS NAME . M, (�,)(`JFAx P NE # ExT. HOME or MAILING ADDR�FSS YV�/✓,, 73 G -L # ) - lI 1 llt�t -7w STATE Zl� CITY I/t� It 226 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 law . APPLICANT'S SIGNATURE: C�,-� DATE: PROPERTY / BUSINESS OWNER 11OPERATOR/ MANAGER 13 OTHER AUTHORIZED AGENT ❑ If APPLICANT is not the BILLING PAlT proof of authorization to sign is required rue 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, )technical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEP as soon as it is available and at the same time it is provided to me or -my representative. TYPE OF SERVICE REQUESTED: ' ?NW D COMMENTS: ptyrXI '�y'/S 1•`$, 1". 1 y.. Ul1t SPN ��tP'LRONMEN.t�'`Nt H�it+DFPAI' ACCEPTED BY: ti EMPLOYEE #: DATE: _ Q ASSIGNED TO: , Q EMPLOYEE #: DATE: Date Service Completed (if already completed): SERVICE CODE: 52Z PIE: 7,��0 2—. Fee Amount:�Invoico# Amount Paid a 11A Payment Date 0 Payment Type Check # b 3 3 Received By: GfZs— EHD 48-02-025 SR FORM (Golden Rod) REVISED 11/17/2003