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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property fizz �1�� FACILITY ID # N SERVICE REQUEST # cIR b6-7&&ol OWNER / OPERATOR 1u" �11 'I 1`(..`( YG U- Si "11, PHONE# EXT. z 5 - 0 3 CHECKIf BILLING ADDRESS ! FACILITY NAME c' W d FAX# ( 1)a 2) 661-f- C 2L CITY I ve- SITE ADDRESS 2-- I Street Number N Direction T�� LY QLt/h ( Street Name �%z Iki- I I q-53 K Zip Code HOME Or MAILING ADDRESS (If Different from Site Address) 2 (o &-B(-'C Street Number w S C^ Street Name CITY --rf- /J A G Y STATE GA ZIP h PHONE #1 Ea . t ) &2,-5) ��7 — D� k6 APN # EMPLOYEE #: DATE: / _ / F J LAND USE APPLICATION # PHONE #2 EXT' ( ) 0 (E)-7,32- - O I')0 EMPLOYEE #: DATE: / _ / I BIDS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR -(ry t' SIrJ l� !`I (' -�-d CC) CA Art Yt?-AkO-, CA L(�") CHECK If BILLING ADDRESS l- BUSINESS NAME CE,'J( -1 ( t7 - Gra PHONE# EXT. z 5 - 0 3 HOME or MAILING ADDRESS k 61 S -I- FAX# ( 1)a 2) 661-f- C 2L CITY I ve- STATE tjf ZIP 8 Ci I 0 BILLING ACKNOWLED(aEMENT: 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: r DATE: I 13 1 PROPERTY / BUSINESS OWNER 13 OPERATOR /MANAGE ❑ OTHER AUTHORIZED AGENT Y- Yv,G If APPLICANT i5 not the BILLING PARTY proof of authorization to sign is required Tir[ 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 ENVIRONMENTAL HEALTH DEPARTMENT as soon as It Is available and at the Same time It Is provided to me or my representative. lowvuruw EHD 48-02-025 SR FORM (Golden Rod) 07/17/08 TYPE OF SERVICE REQUESTED: COMMENTS: 2017 SAN INTY RON E AL NEALTH DEPARTMENT ACCEPTED BY: EMPLOYEE #: DATE: / _ / F J ASSIGNED TO: I5 I EMPLOYEE #: DATE: / _ / I Date Service Completed (if already completed): SERVICE CODE: PIE: j Fee Amount: i Amount Paid Payment Date Payment Type Invoice # Check # Received By: EHD 48-02-025 SR FORM (Golden Rod) 07/17/08