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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID # SERVICE REQUEST # j PHONE# EXT. CALL(209)953-7697 FOR INSPECTION. 48 HOUR NOTICE REQUIRED. S -(Z w OWNER / OPERATOR HOME or MAILING ADDRESS S! lI Cis CHECK If BILLING ADDRESS FACILITY NAME EMPLOYEE #: CITY S SITEADDRESS 17gw 3 A, � �. y� f 1G RG.tx'" SERVICE CODE: ( ' P / E: L) '� va Fee Amount: $'ra Street Number Direction Street Name L� City Invoice # Zip Code HOME Or MAILING ADDRESS (If Different from Site Address) �� Received By: "Y'-i_ Q- <>. Street Number Street Name CITY STATE ZIP PHONE #1 EXT. APN # LAND USE APPLICATION # (ter) I CS11-1000C-D PHONE #2 EXT. ( ) BOS DISTRICT y I LOCATION CODE C7 C4 CONTRACTOR / SERVICE REQUESTOR REQUESTOR U CHECK If BILLING ADDRESS BUSINESS NAME PHONE# EXT. CALL(209)953-7697 FOR INSPECTION. 48 HOUR NOTICE REQUIRED. ACCEPTED BY: G— �'� -+) f3 7 HOME or MAILING ADDRESS FAX # ASSIGNED TO: (" EMPLOYEE #: CITY S STATE ZIP J A BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent tet' ENT acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with t11Rraeole'VED 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 JUN'21 2021 COUNTY Ordinance Codes, Standards, S;A��TERALws. �`f APPLICANT'S SIGNATURE:_ SAN JOAQUIN COUNTY DATE: 10L4 /ENVIRONMENTAL PROPERTY /BUSINESS OWNER ❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT HEALTH DEPARTMENT 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: Ve f r ,Ir) )7 P 1 1 U l 1 f�n�j f U yy1errJY� bc= II y p�Yrl �p SF; }/L �C nK' . COMMENTS: CALL(209)953-7697 FOR INSPECTION. 48 HOUR NOTICE REQUIRED. ACCEPTED BY: G— �'� EMPLOYEE #: DATE: G J Gf N ASSIGNED TO: (" EMPLOYEE #: DATE: a 7 Date Service Completed (if already completed): SERVICE CODE: ( ' P / E: L) '� va Fee Amount: $'ra Amount Paid -Z — Payment Date L� Payment Type l Invoice # C eck # �'Z �� Received By: EHD 48-02-025 SR FORM (Golden Rod) REVISED 11/17/2003