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�a('o0 SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property ' . C J i CHECK if BILLING ADDRESS /'7 //L C' 1 FACILITY ID # r t �� a. l �U SERVICE REQUEST # HOME or MAILING ADDRESS FAX# CITY, `L' t'� STATE C{ ZIP ! 7 OWNER / OPERATOR � /I'll S' CHECK If BILLING ADDRESS lel. I � /— �i,� L I y FACILITY NAME SITE DRESS ENVIRON Street Number Direction 1 i J 8[reet Name Cit ` Zip Code HOME or MAILING ADDRESS (If Different from Site Address) EMPLOYEE #: DATE: 12 L � 17 0 el, L Street Number Street Name CITY SATE Zip , SERVICE CODE: Sa3 PHONE #1 EXT•T9,�2Z, Ol J3 PN # LAND USE APPLICATION # Amount Paid 0 k- - 0-0 2- 0?J00)S3 PHONE #2 EXT. Payment Type BOS DISTRICT LOCATION CODE ( ) CONTRACTOR / SERVICE REQUESTOR REQUESTOR 7 [/L ' . C J i CHECK if BILLING ADDRESS /'7 //L C' 1 BUSINESS NAME s r t �� a. l �U PHO NE # EXT. 'rc ,C' - HOME or MAILING ADDRESS FAX# CITY, `L' t'� STATE C{ ZIP ! 7 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, Standard , STAT- and Fli2tR�k laws. APPLICANT'S SIGNATURE: --- DATE: 1 � PROPERTY / BUSINESS OWNERp f y PERATOR /MANAGER ❑ OTHER AUTHORIZED AGENT ❑ 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 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: Sv f fei« omcj St,/lJs,,f Cw-- C.�Y1 �G%IYtlnLy ��JYt t -C Dr Revle� COMMENTS:1 Pecelv'ed k�I�uyl, Dropbox Del)a aI/a�, �,��,)e �,'le /I'll tJ y nj�FG{ot, OEC SANJOAQU ENVIRON HEALTH DE ACCEPTED BY: —j EMPLOYEE #: DATE: 12 L L ASSIGNED TO:< EMPLOYEE #: DATE: I Z Z Date Service Completed (if already completed): SERVICE CODE: Sa3 P / E: Ol J3 Fee Amount: 3 y Amount Paid 0 k- - Payment Date 1 2 21 L % Payment Type Invoice # Check # Z 3 7 b Received By: EHD 48-02-025 REVISED 11/17/2003 SR FORM (Golden Rod) ENT IVED 1 2021 N COUNTY ENTAL ARTMENT