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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID # PHONE # ExT' SERVICE REQUEST # FAx# _ 20o q 51(�Cl OWNER/ OPERATOR CHECK If BILLING ADDRESS I A FACILITY NAME SITEADDRESS N �aJ//{ �, {.,� /� 9/4 Street Number Dlrectlon 2- s Set Name is Cit ZI Code EMPLOYEE #: DATE4-9---2- _ 9 -2 IG(/'_ !2 AsSIGNEDTO: l?��G HOME Or MAILING ADDRESS (If Different fromSiteeAddreess) DATF�-_ t DateServiceCompleted (if already completed): 7 3�o J L l N R ^r f1J Street Number StreetNama CITY Dt AJSTATE Fee Amount: Y7i Z PH0NE#1 ExT• APN # PaymentDate LAND USE APPLICATION # I2-Z��- i PHONE#2 Ex . ( ) BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR CHECK if BILLING ADDRESS BUSINESS NAME PHONE # ExT' HOME or MAILING ADDRESS FAx# 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, A E az FED • laws. APPLICANT'S SIGNATURE• !/ DATE: PROPERTY/ BUSINESS OWNER OPERATOR/ MANAGER OTHER AUTHORIZED AGENT 11 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 ENv[RONMENTAL HEALTH DEPARTMENT as soon as it is available anda�Y�6g1]Ie time it is provided to me or my representative. 0AP. eNr TYPE OF SERVICE REQUESTED: „Z c lJ"-{-"Fl�i� [ l •e t WWI)— COMMENTS: COMMENTS: 18 2022 SANJ0AQUIN HFAI n TN DEp eNrq� �TMENr 2- s ACCEPTED BY: e rtvry f C J EMPLOYEE #: DATE4-9---2- _ 9 -2 IG(/'_ !2 AsSIGNEDTO: l?��G EMPLOYEE DATF�-_ t DateServiceCompleted (if already completed): SERVICE CODE: 5�%- PIE: Fee Amount: Amount Paid / PaymentDate I� I2-Z��- i Payment Type Invoice # 1'f 2 bZ Received By: EHD 48-02-025 SR FORM (Golden Rod) REVISED 11/17/2003