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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID # SERVICE REQUEST # HOME or MAILING ADDRESS FAX# 15-0 7V0 S 1 OWNER / OPERATOR Dsp ,T � p4 _ �-F CHECK If BILLING ADDRESS FACILITY NAME 7, ur ENVIRONMENTAL SITEEATD�DRESS ISO jda/Z--R{WDODS f}(�4t' HEALTH DEPARTMENT MAiv TL—cm ate. No1u"tltw)0D5?St at Number i n treat Name ASSIGNED TO: city`i'lGotle EMPLOYEE M HOME or MAILING ADDRESS (If Different from Site Address) • l SO n 1 O �'�,{ W ODDS At) " -E7Street Number t Nmo CITY( I � (2 STATE ZIp5— (� PHONE #1 EXT. APN # 5 '� LAND USE APPLICATION # tf (qW-) 21gr -r /f'r aL Payment Date 23 I 1 Payment Type ✓ PHONE #2 EXT ( ) Check # 1 00b BO$ DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR A p CHECK if BILLING ADDRESS I� A`fc—LJ BUSINESS NAME _ S� PHONE# ' HOME or MAILING ADDRESS FAX# 15-0 7V0 ( ) ZIP d` CITYSTATE A In 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 [have prepared this applicati nand th et tfi� Zo b Ierformed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, Standards, STATE d FED RAL laws. APPLICANT'S SIGNATURE: DATE: (S-03-19 PROPERTY/ BUSINESS OWNERO OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT JfAPPLicANT 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. Pio mpwr TYPE OF SERVICE REQUESTED: G k- RECEIV COMMENTS: DEC 13 1019 SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT ACCEPTED BY:L EMPLOYEEM d DATE: ASSIGNED TO: EMPLOYEE M DATE: Z 2 Date Service Completed (If already completed): SERVICE CODE: PI IVD Fee Amount: 5 '� Amount Paid ) L, D r Payment Date 23 I 1 Payment Type ✓ Invoice # Check # 1 00b I Received By: EHD 48-02-025 SR FORM (Golden Rod) REVISED 11/17/2003