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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID # CHECK if BILLING ADDRESS SERVICE REQUEST # COMMENTS: Dw�en} c�+S�'6tNcFs -b PevJ �Ippasc�cin6,1c, fon- RECEIVED PHONE # (76d) EXT. 6 a5- HOME Or MAILING ADDRESS CALL (209) 953• FAX # CITY S OWNER RATOR A CHECK If BILLING ADDRESS ,I, J, C 45OA ENVIRONMENTAL FACILITY NAME ACCEPTED BY: /! Li `� HEALT-14 EMPLOYEE M SIT��V 4T DATE: s� �' e EMPLOYEE #: Street Number Direction SERVICE CODE: j Street Name P / E: Ll a c1tv ZIP Code HOME Or MAILING ADDRESS (If Different from %�ite Address) ` Q 6� 2J - Payment Type Invoice # Strt.d tumber Street Name CITY l STAB � Zl�i�s (z PHONE #1 Exr.N AP # s3g-OLJI LAND USE APPLICATION # (1-7b /,)) � s c PHONE #2 Err. ( ) BOS DISTRICT:�=LOCATION CODE CONTRACTOR / SERVICE REQUESTOR I REQUESTOR II CHECK if BILLING ADDRESS BUSINESS NAME COMMENTS: Dw�en} c�+S�'6tNcFs -b PevJ �Ippasc�cin6,1c, fon- RECEIVED PHONE # (76d) EXT. 6 a5- HOME Or MAILING ADDRESS CALL (209) 953• FAX # CITY S STATE,,, ZIP C� 5 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 STAT.4 and FEDERAL laws. APPLICANT'S SIGNATURE: DATE: [/ (,rJ/tom vi� PROPERTY / BUSINESS OWNE 'OPERATOR/ 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 at the same time it is provided to me or my representative. TYPE OF SERVICE REQUESTED: e, y t P• I iJ X61 }I -v o p 1 COMMENTS: Dw�en} c�+S�'6tNcFs -b PevJ �Ippasc�cin6,1c, fon- RECEIVED CALL (209) 953• �UN 2 8 2022 FOR INSPECTIO f� L 24-HOUR NOTII SAN JOAQUIN COUNTY REQUIRED. ENVIRONMENTAL ACCEPTED BY: /! Li `� HEALT-14 EMPLOYEE M DERAR ME 4T DATE: ASSIGNED TO: �YL EMPLOYEE #: DATE: Date Service Completed (if already completed): SERVICE CODE: j P / E: Ll a Fee Amount: 1 Sa Amount Paid Ga -- Payment Date 6� 2J - Payment Type Invoice # 291 Received By: ".0 EHD 48-02-025 REVISED 11/17/2003 SR FORM (Golden Rod) 7697 N.