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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property S��=1� !► FACILITY ID # SERVICE REQUEST # U AMi/l I r P�-a s ��PhC Ioebn .NE EXT. PHO q i -7qu- z ,K HOME or MAILING ADDRESS /Y( JY v (i A! FAX # — CITY l t- STATE 0A L _ ZIP -1 �I ✓ 41 OWNER / OPERATOR Oi� �(T 0 - La ACCEPTED BY: CHECK if BILLING ADDRESS FACILITY NAME ASSIGNED TO: 1 + C f V SITE ADDRESS � C--) SERVICE CODE: Drive— s CI"Street DoAmount '3M' .r/ •l� )Vv I (x�Ciitt, (v C�SLV� t Street Number Direction Payment Type / 5�� Name Check # f S8 Received By: 2i Code HOME Or MAILING ADDRESS (if Different from Site Address) Street Number Street Name CITY STATE ZIP PHONE#1 Exr. �/ n APN # LAND USE APPLICATION # PHONE #2 EXT. ( ' 41);,L,�� &-fL' 'o BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR S��=1� !► CHECK if $fLLiNG ADDRESS BUSINESS NAME r P�-a s ��PhC Ioebn .NE EXT. PHO q i -7qu- z ,K HOME or MAILING ADDRESS /Y( JY v 7 FAX # — CITY l t- STATE 0A L _ ZIP -1 �I ✓ 41 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 aiau '4srepaTed 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 SIGNATURE: DATF:_Q� PROPERTY / BUSINESS OWNER❑ OPERATOR / ANAGER ❑ OTHER AUTHORIZED AGENT' L7•. 1 J F✓ �f APPLICANT is not the BILLING PARTY, proof of authorization to sign is required �t Title AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located :rt tip above site address, hereby authorize the release of any and all results, geotechnical data and/or environmcntallsite assessment information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at tIPAI Cit ' provided to me or my representative. RFrM TYPE OF SERVICE REQUESTED: _ --mss e/CL� COMMENTS: 2021 �`� �� l'f E (k�1✓yL S SAN JOAQUIN COON ENVIRONMENTAL HEALTH D Oi� �(T 0 - La ACCEPTED BY: EMPLOYEE #: DATE: ASSIGNED TO: ( EMPLOYEE #: DATE: ` Date Service Completed (if alrea completed): SERVICE CODE: Fee Amoun DoAmount Paid ,2 j d(� Payment Date /3 Payment Type / 5�� Invoice # Check # f S8 Received By: EHD 48-02-025 SR FORM (Golden Rod) REVISED 11/17/2003