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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property CHECK If BILLING ADDRESS Air FACILITY ID # SERVICE REQUEST # P® JUN SAN O 6 FrV �AQU!IV H� H p� �NTqN rl' PHONE# EXT. � 0 ucT DATE: r n HOME or MAILADDRESS I DATE: G 4 as FAX # SERVICE CODE: Sa 31 OWNER/ OPERATOR CITY STATE ZIP Amount Paid Payment Date CHECK If BILLING ADDRESS Er FACILITY NAME Invoice # Check t3ft SITE ADDRESS 34- g I/ Cy�Ry�A�vD ✓ENt.�! 5TocK'jo11/ T�.?/a� Street Number Direction Street Name City Zip Code HOME Or MAILING ADDRESS (If Different from Site Address) Fo . ook Street Number Street Name CITYTo C � S 1 C? STAT�F ZIP (?A / PHONE #'1 EXT. APN # LAND USE APPLICATION # (a") ?9/- 73 007-0p-� t64 PARI o a rpHONE #2 ( ) EXT. BOS DISTRICT LOCATIONC E CONTRACTOR / SERVICE REQUESTOR REQUESTOR CHECK If BILLING ADDRESS Air COMMENTS: BUSINESS NAME P® JUN SAN O 6 FrV �AQU!IV H� H p� �NTqN rl' PHONE# EXT. � 0 ucT DATE: r colo - s HOME or MAILADDRESS I DATE: G 4 as FAX # SERVICE CODE: Sa 31 ( ) 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 fort -n. I also certify that I have prepared this I COUNTY Ordinance Codes, Standards, APPLICANT'S SIGNATURE: PROPERTY / BUSINESS OWNER ❑ OPERATOR/ and th i work to be performed will be done in accordance with all SAN JOAQUIN FE RA ws. G DATE: ANAGER ❑ O tIER AUTHORIZED AGENT 121 If APPLICANT is not the BILLING PARTY, proof of authdilation 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 me or my representative. J!1A TYPE OF SERVICE REQUESTED: .5:5 EV 1 e Air COMMENTS: P® JUN SAN O 6 FrV �AQU!IV H� H p� �NTqN rl' ACCEPTED BY: �� lj !. EMPLOYEE #: DATE: r ASSIGNED TO: Cron k F EMPLOYEE #: DATE: G 4 as Date Service Completed (if already completed): SERVICE CODE: Sa 31 P / E: a (oda Fee Amount: (p D Amount Paid Payment Date ( �2 Payment Type Invoice # Check t3ft Received By: EHD 48-02-025 SR FORM (Golden Rod) REVISED 11/17/2003