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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property �o ( ^ n ,� �1 � U CHECK if BILLING ADDRESSJP FACILITY ID # SERVICE REQUEST # &)dq� HOME or AILING ADDRESS Rve S�nc��.5.2-2 OWNER I O ERATOR CHECK If BILLING ADDRESS FACILITY NAME ' SITE ADDRESS ��C� S �-�U �l �t5�.q Street Number Direction Street Name city Zip Code HOME or MAILING ADDRESS (If ifferent from Site Address) G1 / /� (� -`� Pr /� Street Number M Ukr l ` ` `� ` Street Name CI STATE ZIP / C IN, (`V PHONE #1 ExT• APN # LAND USE APPLICATION # (20c1 ) qQ_7 #2 ExT• ( ) ----7PHONE BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR'N 1 C�6 �e �o ( ^ n ,� �1 � U CHECK if BILLING ADDRESSJP BUSINESS NAME �' ` W IvI v 1 l' I f,Uk- '1 i l.' PHONE# qO _-2 2 ExT. HOME or AILING ADDRESS Rve FAX # CITY M( a C t) ec CA 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 an4 FE laws. APPLICANT'S SIGNATURE: !9,�j, j ;n� �Xy DATE: (� aC PROPERTY / BUSINESS OWNF(Ija 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: C Of I LFA n n Kt Rat2 COMMENTS: D SPR 112022 SAN JOAQUIN COU1EAfV TY �e ARTMFNT ACCEPTED BY: I EMPLOYEE #: Q DATE: 2 ASSIGNED TO: EMPLOYEE #: DATE: r 1 Date Service Completed (if already completed): SERVICE CODE:i PIE: 44/= PyFee Amount: 5 Amount Paile/s Payment Date Payment Typ Invoice # Check # ��- �`�� Received By: EHD 48-02-025 SR FORM (Golden Rod) REVISED 11/17/2003