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JP SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property CHECK If BILLING AD FACILITY ID # SERVICE REQUEST # � e- S 1' 8&1 � 01A FAx# JG A U1N CITY 5 �y Cl �CNE;o 10 OWNER/ OPERATOR rN CL 65J 65-Vt k l ` (V -0�?(kl If BILLING ADDRESS FACILITY NAME o FOR INSPI SITE ADDRESS � r C..� vSt�reet �` (*j' ' , + J�{- �-�"'' ` 7 l C Fq Street Number D rection ( tion St Name DATE: ZI CoGd_e HOME Or MAILING ADDRESS (If Different from Site Address) EMPLOYEE M DATE: Street Number Street Name CITY P / E: STATE ZIP PHONE #1 EXT. Amount Pai APN # y'� G %� D ? 1 3OS/% LAND USE APPLICATION # PHONE #2 EXT• Payment Type �' - BOS DISTRICT LOCATION CODE Check # !t (�(P ��I Received By: CONTRACTOR / SERVICE REQUESTOR REQUESTOR ` 11 , I. ( G 1 vl (�� CHECK If BILLING AD BUSINESS NAME PHONE# SNA 16 HOME MAILING DDRES r _ Q FAx# JG A U1N CITY 5 �y Cl STATE ZIP J l I J ENT VED 2022 oUNTY rAL MENr 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 iden&dhism. I also certify that I have prepared t ' ap ' atio be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, Stand ds, STA E d APPLICANT'S SIGNATURE: DATE: (v Z PROPERTY / BUSINESS OWNER OP RATOR / MANOG R ❑ OTHER AUTHORIZED AGENT ❑ If APPLICAN is not the BILLING PARTY, r of 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 ITIe or my representative. TYPE OF SERVICE REQUESTED: L I COMMENTS: C 14Fi-LV �I Y1fS ✓V!EE'1 S'� �IOL';LJGS �0 1 IIGl� G'I Clot l rkwl' v / CALL (209) FOR INSPI 24-HOUR REQUIR ACCEPTED BY: �'�� EMPLOYEE #: DATE: ASSIGNED TO: Ff l9 o k EMPLOYEE M DATE: Date Service Completed (if already completed): SERVICE CODE: O� P / E: I �� Fee Amount: f S Amount Pai /1 a CJ Payment Date Payment Type �' - Invoice # Check # !t (�(P ��I Received By: EHD 48-02-025 SR FORM (Golden Rod) REVISED 11/17/2003 953-7697 :CTION. NOTICE ED.