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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property CHECK BILLING ADDRESS FACILITY ID # If SERVICE REQUEST # �-r� OME or MAILING ADDRESS FAX# EMPLOYEE #: DATE: 55 OWNER / OPERATOR CHECK If BILLING ADDRESS FACILITY NAME Date Service Completed (if already completed): 2 ZZ Ylill SITE ADDRESS 2 c l D V PIE: r-7 rte— ' fn () r Y � Amount Pald "1 Street Number Direction Street Name CI Zipip Code HOME or MAILING ADDRESS (If Different om Site Address) e7 �/ Street Number Street Name CITY STATE ZIP PHONE #'I EXT. ( ) APN # !% " C-) LAND USE APPLICATION # PHONE#2 EXT. BOS DISTRICT CATION CODE ( ) 1 1 i CONTRACTOR / SERVICE REQUESTOR EQUESTOR CHECK BILLING ADDRESS If BUSINESS NAME PHONE# EXT. Oti) �)Sl- Z%CT-S OME or MAILING ADDRESS FAX# EMPLOYEE #: DATE: CITY n^ CA . STATE ZIP p,'i�j �6 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 SIGNATURE: V\ DATE:` PROPERTY/ BUSINESS OWNER 011114ATOR /MANAGER ❑ OTHER AUTHORIZED AGENT ❑ If APPLICANT is not the BILLING PARTY_proof of authorization to sign is required Title PAYMENT AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property lo �� t�� above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site asses information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the samj,�UJore it 2022 provided to me or my representative. /1 00 TYPE OF SERVICE REQUESTED: SAN JOAQUIN E I COM(�NTS: n `/� C j_ �/) -Cil' L V) P— ( A /%Q s r Cu- %.O -Y\ /�, f ` . ' /� I c �/� /9—l^ HEALTH DEP tel, (� � b �/V C�� ` > ✓ � ` �� L f� ' '^ to k -f S d Lc-+ e Aj so - Q 1 C i% ' St,Y e ACCEPTED BY: EMPLOYEE #: DATE: 2 ASSIGNED TO: EMPLOYEE #: DAT Date Service Completed (if already completed): 2 ZZ Ylill SERVICE CODE: PIE: Fee Amount: Amount Pald Payment Date g 2� Payment Type �' k l Invoice # ck # / 5a �, Received By: EHD 48-02-025 SR FORM (Golden Rod) REVISED 11/17/2003 OUNTY VTAL TMENT