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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property BUSINESS NAME +r/t U,`A R �k- CUM\)C� 'I FACILITY ID # HOME or MAILING ADDRESS ' 1 I Ifl I f1�rr. n �`' ^ �i D ' �f r � Y'�1 V �C SERVICE REQUEST # C CITY `�N STATE IPI- ZIP ACCEPTED BY: vr. ec Lp EMPLOYEE DATE: y-1G�22 s) 0& q OWNER /OPERATOR DATE:'L -ZS( _-27 Date Service Completed (If already completed): .-.r G CHECK If BILLING ADDRESS FACILITY NAME QL 1 Amount Paid SITE ADDRESS -L3 U ''%% Payment Date ` 10 \� � IJ�Str`eet Payment Type /�\ /�� �7 �, _I A I S Street Number Direction Name CI 2i Code HOME or MAILING ADDRESS (If Di fferent fr m Site Address) C\ t� Street Number Street Name CITY 5kt0(-; _,^\ STATE ZIP l� PHONE #1 Ex . APN # LAND USE APPLICATION # ("+) m-004 PHONE #2 EX . BOIS DISTRICT LOCATION CODE ( ) IS 03 CONTRACTOR / SERVICE REQUESTOR REQUESTORnt/ k lA�l O WUt lQv""Z r'� �,(,�,ryt ii /) ' 11111 �,y' CHECK If BILLING ADDRESS T'�\ BUSINESS NAME +r/t U,`A R �k- CUM\)C� 'I PHONE# E�`' HOME or MAILING ADDRESS ' 1 I Ifl I f1�rr. n �`' ^ �i D ' �f r � Y'�1 V �C FA%# ( ) C CITY `�N STATE IPI- 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. APPLICANT'S SIGNATURE: I at,& DATE: OZ( 2$ ` J pptt �— PROPERTY / BUSINESS OWNEROI OPERATOR /MANAGER ❑ OTHER AUTHORIZED AGENT ❑ IfAPPLICANT is not the BILLING PARTY proof of authorization to sign is required Title AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, 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/ essment information to the SAN JOAQUrN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It is available and at [ provided to me or my representa 've.0 TYPE OF SERVICE REQUESTED: �. ,e,e. hE(j COMMENTS: 'W ft;iJQyQut 37 )1i p9N - , LNrI y ACCEPTED BY: vr. ec Lp EMPLOYEE DATE: y-1G�22 ASSIGNEDTO: ot EMPLOYEE#: DATE:'L -ZS( _-27 Date Service Completed (If already completed): SERVICE CODE: P /E: O Fee Amount: �^ Amount Paid Payment Date zhffr�3 Payment Type Invoice # 5 3 t 34 Received By: EHD 48-02-025 SR FORM (Golden Rod) REVISED 11/17/2003