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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property CHECK If BILLING ADDRESS YYYY//// V PE FACILITY ID # BUSINESS NAME CY�-s NF SERVICE REQUEST # PHONE# EXT. 02P:6Z- - s HOME or MAILING AU.PRESS EMPLOYEE#: elF-7 FAX # (� �, OWNER / OPERA�7TOOR CITY ) 2-LDe STATE CAZIP "lel I�/?' 6t �,�✓. /`�$ E/V - / I=RSK/AAEE CHECK If BILLING ADDRESS FACILITY NAME Payment Date Payment Type SITE ADDRESS 3QGG7 5 ke -5TEt2 Received By: Street Number Direction Street Name Cit Zip Code HOME Or MAILING ADRESS (If Different from Site Address) 'S,4 ME Street Number Street Name CITY STATE ZIP PHONE #1 EXT. APN # LAND USE APPLICATION # (-'-'1a(v5-1va3-4 -3--)-o-// PHONE #2 ( 1 EXT. BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR �t9/ CHECK If BILLING ADDRESS YYYY//// V PE COMMENTS: BUSINESS NAME CY�-s NF MAIC 10 2022 SAN JOAQUIN COUN ENVIRONMENTAL HEALTH DEPARTME PHONE# EXT. 02P:6Z- - s HOME or MAILING AU.PRESS EMPLOYEE#: elF-7 FAX # (� EMPLOYEE #: CITY ) 2-LDe STATE CAZIP "lel 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 COUNTY Ordinance Codes, Standards APPLICANT'S SIGNATURE: PROPERTY/ BUSINESS OWNER❑ OPERA ion and tl t the work to be performed will be done in accordance with all SAN JOAQUIN and F ' laws. DATE: X;� IR/ 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 atIa3�tLGle■ s provided to me or my representative. A� Mtn TYPE OF SERVICE REQUESTED:5.5AILE:: V/ COMMENTS: MAIC 10 2022 SAN JOAQUIN COUN ENVIRONMENTAL HEALTH DEPARTME ACCEPTED BY: aat►t EMPLOYEE#: elF-7 DATE: V ASSIGNED TO: C�j7 4 S EMPLOYEE #: DATE: Date Service Completed (if already completed): SERVICE CODE: `S�3 P 1 E: -0-(o O Z Fee Amount: Amount Paid — Payment Date Payment Type Invoice # Check # Received By: EHD 48-02-025 REVISED 11/17/2003 SR FORM (Golden Rod)