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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID# SERVICE REQUEST# vakr v ena inq 01 machor)f, S\?,WRA4"5 OWNER/OPERATOR MnMfl l! 1 A I �Qq � CHECK If BILLING ADDRESS FACILITY NAME ,(� t*` f��v��`,ayxv�� SITEAMRESS qt 600)6" kn '[)rR►Pon 19 S3 LPte Stroet Number Direction Street ame city Zip Code HOME 0 MAILING ADDRESS (If Different from Site Address) Street Number Street Name CITY STATE ZIP PHONE#1 EXT. APN# LAND USE APPLICATION# (za1) 2 39 3 I l ri PHONE#2 Err. BOS DISTRICT LOCATION CODE ( ) CONTRACTOR/ SERVICE REQUESTOR REQUESTOR CHECK if BILLING ADDRESS❑ BUSINESS NAME �r-e PHONE EXT. 361 3t I '1 HOME or MAILING ARE FAX# 951 Ca.00eiwin ri Ve- o oa) 9 39 60(.01 CITY t Oh STATE CQ ZIP 95 Lo BILLI14G 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 F ERAL laws. APPLICANT'S SIGNATURE: �• DATE: (pll5/�a 3 PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGERfYJ OTHER AUTHORIZED AGENT[3IfAPPLICANT 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 tineit?ME provided to me or my representative.��7 C— f Lei 7 �� TYPE OF ERVICE REQUESTED: 1 4 L•} 6 RECELVED COMMENTS (X S Clu C �"'L wtL S S�_<__v� L,IJ� E-�-r_ J 6 2O23 C SAN JOAQ IN COUNTY ENVIROMENTAL ` HEALTH DE ARTMENT ACCEPTED BY: r/I,�S EMPLOYEE#: DATE: ASSIGNED TO: 2�V vv,-iq EMPLOYEE#: DATE: Date Service Completed (if alreatly completed): SERVICE CODE: ��j� ( 6y 1 E: Fee Amount: /S Amount Paid S� Payment Date Z Payment Type C c, P�- I invoice# C,f ael�# �� g g p Received By: EHD 48-02-025 SR FORM(Golden Rod) REVISED 11/17/2003