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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID # CHECK If BILLING ADDRESS SERVICE REQUEST # 1 Co uC� D PHONE# , \ — �F �Q ExT• r2pq _✓ SV- 003-\1-2-> OWNER/ OPERATOR FAX# J\ JLV C (�(� tt � S CHECK If BILLING ADDRESS FACILITY NANI CO S E C SITEADDRESS ACCEPTED BY: C OVVW nULi —L EMPLOYEE #: DATE: G /] /)-\ \J ASSIGNED TO: J , � O DATE: \ ^L' ^ -}- Qrt -1r�y_`,/� � "C P / E`: -2 Street Number Direction eet �l \ Payment Date• l 1 V I I Zlo Code HOME Or MAILING ADDRESS If Different fromSite Address) Received By: I v `—� 4-1 Street Number Stmel Name TOn STAT ZI P ONE#1 EaT• APN # LAND USE APPLICATION # PflQNE 2 BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUES OR -r `l_Jlzte CHECK If BILLING ADDRESS BUSINES Mfg O CI�V cA D PHONE# , \ — �F �Q ExT• r2pq _✓ HomEor MAILING DDRESS MAY ? 6 2021 FAX# 10 (�(� tt � S ( ) C STATE ZIP q S() O BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge t11at 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. n / APPLICANT'S SIGNATURE J,n)( i. DATE: PROPERTY / BUSINESS OWNER OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT ❑ I,fAPPLICANT is not the BILLING PARTY proof of authorization to sign is required Title AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, 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 the or my representative. TYPE OF SERVICE REQUESTED: E.` COMMENTS:Jive D MAY ? 6 2021 'AN JOAQuiV IiLHEMTYSApEN7AL ACCEPTED BY: C OVVW nULi —L EMPLOYEE #: DATE: G /] /)-\ \J ASSIGNED TO: J , � EMPLOYEE M DATE: \ ^L' ^ Date Service Completed (if already completed): SERVICE CODE: X72i -s P / E`: Fee Amount: Payment Date• l Payment Type QC5 b Invoice # Check # Received By: EHD 48-02-025 SR FORM (Golden Rod) REVISED 11/17/2003