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CALL (2�3) 953-7697 SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT FOR INSPECTION. 24-HOUR NOTICE SERVICE REQUEST RE LtultctU. Iss or Property FACILITY ID # s D .1 r l t✓. V P (' �/ )J (:et l in f 1 -,wll �e- 166rc,)oo is Q�1 SERVICE REQUEST # BUSINESS NAME PHONE# EXT. Aaiw7T .1/ 1;j2 C) 0 qq OWNER / OPERATOR FAX # /631 Li✓TI+A INK i -L - req' CHECK If BILLING ADDRESSu FACILITY NAME U �� PIE: SITE ADDRESS 14 ySU Amount Paid pq, �l.F' Payment Date Z �D 4 Street Number Directlon N11� Set Nfie cit ZI HOME or MAILING ADDRESS (If Different from Site Address) Street Number Street Name CITY STATE ZIP AUG 6 PHONE #1 EXT. APN # �� • LAND USE APPLICATION # uV E OaQI/IN C R9/VAf ( ) o �� H� PHONE #T EXT. BOS DISTRICT l l LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR CHECK If BILLING ADDRESS s D .1 r l t✓. V P (' �/ )J (:et l in f 1 -,wll �e- 166rc,)oo is Q�1 ACCEPTED BY: �� i� BUSINESS NAME PHONE# EXT. Aaiw7T .1/ 2L HOME Or MAILING ADDRESS FAX # /631 DATE: CITY �J D) 5 STATE ZIP ►FtiT VFX 20?1 SAL FENT 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 laws. APPLICANT'S SIGNATURE: T— DATE: PROPERTY / BUSINESS OWNER❑ OPERATOR/ MANAGER ❑ OTEIER AUTHORIZED AGENT ® CatJ't A( -'MR - If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required Vile 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: Ver'JI (;Z)&'4/Jr Q f st* -i'( -':yS1eM COMMENTS: 1 h 1"10 S 'P ��tyllC �ty,(;1 1Ft;�N l�t�< fv EhS�'le St j�o4'o�! s D .1 r l t✓. V P (' �/ )J (:et l in f 1 -,wll �e- 166rc,)oo is Q�1 ACCEPTED BY: �� i� EMPLOYEE #: DATE: ASSIGNED TO: EMPLOYEE #: DATE: Date Service Completed (if already completed): SERVICE CODE: U �� PIE: Fee Amount:) Amount Paid O� Payment Date Z Payment Type - Invoice # Check # Receive By: By: 48 -02-025 SR FORM (Golden Rod) REVISED 11/17/2003