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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property � n CHECK If BILLING ADDRESS D D FACILITY ID # SERVICE REQU ST # S'PU0�351 OWNER/ OPERATOR -1 4l V L n Il e C z:2� fir, (� �/n ExT. CHECK If BILLING AOORE55I FACILITY NAME <:J:eDlV\ IS FA%# (f' '1rj 6 LVED 6 SITE ADDRESS Sheet Number S, Direction '( LY Sheet Name C ZIPCode HOME or MAILING ADDRESS (If Different from Site Address) Street Number • Street Name nV /1 ,fit /. 1y �/� \//�j CITY Os- I I U t' I IA I �� I 1 '-' S TE Y/'] ZIP �� 1 PHONE#1 �^ n, L EM APN4 LAND USE APPLICATION PHHOOONNE1�#2 E> . ( ) SOS DISTRICT LOCATION CODE CONTRACTOR,/ SERVICE REQUESTOR REQUESTOR y �'I 1 � n CHECK If BILLING ADDRESS D D BUSINESS NAME �1 — �-7 Ujy �(Cy f ,, I ^■,t II P # fir, (� �/n ExT. /\ HOME or MAILING ADDRESS FA%# CITY LVED 6 STAT 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 applicati d that the work to be performed will be done in accordance with all SAN JOAQUIN CouNTY Ordinance Codes, Standards STATE d EDERAL laws. APPLICANT'S SIGNATURE: DATE: PROPERTY/ BUSINESS OWNERE�— OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT If APPLICANT is not the BILLING PARAproof of authorization to sign is required Title AUTHORIZATION TO RELEASE INFORMATION: W1Ten 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 infomlation 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: AYE y COMMENTS: LVED 6 N� 2021 1Williambreedcom Y1lO�i • QU ENhtmCOU HEALTjOAREP ENTiqN N ACCEPTED BY: a` �, EMPLOYEE #: Q / 1 V DATE: ASSIGNED TO: W�'1� EMPLOYEE#: l DATE: Z/ Date Service Completed (if already completed): SERVICE CODE:: P / E: J // I v Fee Amount: S(Q rt Amount Paid /�;r � Payment Date 2-4 Payment Type M-5 Invoice # Check # Received By: mtw EHD 48-02-025 REVISED 11/17/2003 SR FORM (Golden Rod)