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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID # SERVICE REQUEST # S� 00P �-SS OWNER /OPERATOR V &Kt3� Tom' CHECK If BILLING ADDRESS ❑ FACILITY NAME sqN� ?p2Z 'V (701 SITE ADDRESS SN -7 Street Number I Direction V4r +L -L -Ga Street Name # City Zip Code HOME or MAILING ADDRESS (If Different from Site Address) Street Number (lay ) Street Name CITY STATE CA- STATE ZIP PHONE #1 EXT. ( ) SERVICE CODE: `� APN # le 3- 270 -A6 ' /3 LAND USE APPLICATION # PHONE #2 EXT. ( ) 3� / dlJ BOS DISTRICT LOCATION C 79 CONTRACTOR / SERVICE REQUESTOR REQUESTOR A _ CHECK If BILLING ADDRESS 1 0 BUSINESS NAME (� `, L PHONE# EXT. 66 r 3 sqN� ?p2Z 'V (701 HOME or MAILING ADDRESSFAX # MR MFNn D X EMPLOYEE #: -ZJ�i 1t l (lay ) 77q- t>-7 Z 5 CITY L OiP) STATE CA- 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: PROPERTY/ BUSINESS OWNER ❑ OPERATOR / 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: COMMENTS: JAN 1� sqN� ?p2Z 'V FNIRON '4QU/N COU FACTyOR MR MFNn ACCEPTED BY: EMPLOYEE #: -ZJ�i 1t l DATE: ASSIGNED TO: EMPLOYEE #: �� DATE: / Date Service Completed (if already comple ed): SERVICE CODE: `� P 1 E: Z - Fee Amount:/� "Invoice Amount Paid 1 3� / dlJ Payment Date I Z� Payment Type 17 # Check # 22' l 3 Receive By: EHD 48-02-025 SR FORM (Golden Rod) REVISED 11/17/2003