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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property SINE ) FACILITY ID # HTT LIN AD RESS SERVICE REQUEST # CITY S ` / > ' (— STATE ZIP t�,n>c O?' (/�n✓Tf'G�I�n PX/,3�'S, 10 mJ/r5 r -r sep4bc oil�i')E . CALL (209) 953-7697 p�JI sy37eY� 2 �15�5� 51S); (30/4)1 (',%P,h'Dn �EI r^ G eGk II3�' FOR INSPECTION. CHECK If BILLING ADDRESS 24-HOUR NOTICE SITE ADDRus REQUIRED. M � �t �t EMPLOYEE #: DATE: 1 ASSIGNED TO: A Street Number DiLn 1 Name ) DA2 /A ` C' HOME or MAILING ADDRESS (If Different from Site Address) P / E: a Fee Amount: S� Amount Paid Street Number Payment Date D Street Narm CITY Invoice # STATE ZIP PHONE #1 EXT. Received By: APN # LAND USE APPLICATION # PHONE #2 EXT. BOS DISTRICT LOCATION CODE ( 1 � CONTRACTOR / SERVICE REQUESTOR RE Ur OR CHECK if BILLING ADDRESS `SSV SINE ) PHON Exr. HTT LIN AD RESS FAX# 11 CITY S ` / > ' (— STATE ZIP 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:" DATE: 1012-1 i �y � -262I P"MENT PROPERTY / BUSINESS OWNERlL7 OPERATOR /MANAGER ❑ OTHER AUTHORIZED AGENT ❑ IfAPPLiCANT is not the BILLING PARTY, proof of authorization to sign is required Title RECEIVED AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property to I IfIe2021 above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site a s ssment information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the smaokil4igOUNTY provided to me or my representative. ENVIRONMENTAL " ENT TYPE OF SERVICE REQUESTED: Ve O G ici*) ah bT n o S '1) ( 1-0 n f c Cor e COMMENTS:(tea VPperm-�}PC/MAI'le Dome 4z be ferouvPd. SfG}crJ rki U COnnedi-or` �O S('(71`IL �,Ic,s ne�e� pYicfGAF. U8iir1/ no s�Pt)� t�,n>c O?' (/�n✓Tf'G�I�n PX/,3�'S, 10 mJ/r5 r -r sep4bc oil�i')E . CALL (209) 953-7697 p�JI sy37eY� 2 �15�5� 51S); (30/4)1 (',%P,h'Dn �EI r^ G eGk II3�' FOR INSPECTION. �� 24-HOUR NOTICE REQUIRED. ACCEPTED BY: —� EMPLOYEE #: DATE: ASSIGNED TO: A EMPLOYEE #: DATE: ) DA2 /A Date Service Completed (if already completed): SERVICE CODE: P / E: a Fee Amount: S� Amount Paid Z -- Payment Date D Payment Type (, Invoice # Cheek # j 3 3 3 Ct 8 Received By: EHD 48-02-025 SR FORM (Golden Rod) REVISED 11/17/2003