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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST P 2 o S o Type of Business or Property BUSINESS NAME FACILITY ID # HOME Or MAILING ADDRESS SERVICE REQUEST # CITY STATE ZIP DEC 18 1020 SAN JOAQUIN COUNTY OWNER / OPERATOR _ CHECK If BILLING ADDRESS FACILITY NAME GuliFo�n� ChP�sN�P +�a SITE AD/DR�jESS / 6 J tvt{I.ili'1 C-4 /f n Ma i 4tC✓r¢ety� //�330 �CiI DATE: (i— G Street Number Direction EMPLOYEE#: "-" r Zip Code HOME or MAILING ADDRESS (If Different from Site Address) SERVICE CODE: S�3 P / E: Fee Amount: 4�5—& Street Number 45 Street Name CI T as ll Invoice # sCA SS -3 PHONE #1 Ext. Received By: (� APN # LAND USE APPLICATION # (2,J9) G5 2- 12 05 PHONE#2 Ext. q 30 - 212r BOS DISTRICT 3 LOCATION CODE 12Mi CONTRACTOR / SERVICE REQUESTOR REQUESTOR CHECK if BILLING ADDRESS BUSINESS NAME PHONE # Ev. HOME Or MAILING ADDRESS FAX# I ) 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. \\/ Q' APPLICANT'S SIGNATURE: z� UATE: PROPERTY/ BUSINESS OWNER❑ 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 t0 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. I r%A. �. TYPE OF SERVICE REQUESTED: VJ L �YV T Fimpq COMMENTS: DEC 18 1020 SAN JOAQUIN COUNTY EAMENTAL N ALTH DOE ARTME MENT ACCEPTED BY: �j� ��'� / L O L' EMPLOYEE#: DATE: (i— ASSIGNED TO: EMPLOYEE#: DATE: IZ- , Date Service Completed (if already completed): SERVICE CODE: S�3 P / E: Fee Amount: 4�5—& Amount Paid 45 Payment Date 12 ' Payment Type Invoice # Check # Received By: (� EHD 48-02-025 SR FORM (Golden Rod) REVISED 11/17/2003