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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID # SERVICE REQUEST # �)( 006370 s L \555 OW ER / OPERATOR '� 11CHECK I BILLI G ADDRESS I FACILITY NAME II l ` w✓ ;fie -u SITE ADDRESS 15 _ I r'j� stret✓t Street Number Direction Street Name Cit Zip_1 Code HOME or MAILING ADDRESS (If Different from Site Address) ' A cl CLI CSL t _ Street Number Street Name CITY / &I/_ e '3- STATE CST ZIP PHONE #1 EXT. APN # LAND USE APPLICATION # ( 201 ) 2u7 � j5Z 3 � Zo PHONE #2 EXT. BOS DISTRICT LOCATION CODE ( ) CONTRACTOR / SERVICE REQUESTOR REQUESTOR j � r CHECK If BILLING ADDRESS13 BUSINESS NAME PHONE # ExT. '2 ocl 2 `( 7 — 6 I S `�- HOME Or MAILING ADDRESS FAX # 1533 V� . I ( ) CITY C STATE c1q 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 aFAT ' tion and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, Standards, andFEDERAL1 s . APPLICANT ' S SIGNATURE : � � DATE ; �� J.� / / q 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 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 : S L. C% �. IT AY COMMENTS : yeve� DEC 20 2019 V V/R0�N CouNTM S TH c MQ[V MIS ACCEPTED BY : + t / VI J 1 I ri l U 11!, CCL ^, EMPLOYEE #: DATE : ASSIGNED TO : �1' tl t vv 11'� V� � ! n C' G L'` EMPLOYEE #: DATE : I !Z ZL� �k 1 Date Service Completed ( if already completed) : 2G l9 . SERVICE CODE : G) P I E : 1 Fee Amount : . `� Amount aid Payment Date Payment Type ` -� Invoice # Check # Received By : EHD 025 1 h n —'��J CJ SR FORM (Golden Rod) REVISEDSED 11117/2003 U ' L)