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SERVICE REQUEST Type of Business or Property FACILITY ID# SERVICE REQUEST# til SOoo OWNER/OPERATOR CHECK If BILLING ADDRESS VC 6A 0 VL FACILITY NAME SITE ADDRESS Street Number Direction Street Name City ZIp Code HOME or MAILING ADDRESS (If Different from Site Address) i/C.NL� W 1 K ZV , Street Number Str et Name CITYS TE ZIP ( r V PHONE#1 Exr. APN4 LAND USE APPLICATION# (fit) 52 -s PHONE#2 ExT• SOS DISTRICT LOCATION CODE ( ) CONTRACTOR/ SERVICE REQUESTOR REQUESTOR CHECK if BILLING ADDRESS❑ BUSINESS NAME PHONE# ExT. HOME or MAILING ADDRESS FAx# CITY STATE 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 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. / APPLICANT'S SIGNATUREs�J,-- iDATE: T PROPERTY/BUSINESS OWNERI:J OPERAT /MANAGER ❑ OTHER AUTHORIZED AGENT❑ IJAPPLICANT is not the BILLING PARTY proof of authorization to sign is required Tide 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. R TYPE OF SERVICE REQUESTED: R,EC COMMENTS: P 11E-461 SAN JOIN �2 2021 ENVIRON t N TY HEALTH DE ARTrh NT ACCEPTED BY: EMPLOYEE#: ?/L DATE: _14H _ 1 ASSIGNED TO: EMPLOYEE#: j DATE: Date Service Comp ted (N already comPleted): SERVICE-CODE: Fee Amount: Amount Paid ��(o-6t� Payment Date Payment Type Invoice# Check# 1 f 9S [{�j Recei ed By: REVISED 11/17120033 fwvuo ` 4 µr EHD `' 1 "�� l l SR FORM(Golden Rod)