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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID # SERVICE REQUEST # �Q S +0' 1 oil, 3LI `R O V D y S OWNER I OPERATOR / � ,(/a v1 e n •� � t � / , � CHECK If BILLING ADDRESS FACILITY NAME A f� e yO� ^ +�C 1 SITE ADDRESS ti 1 r 1 C) e m k aD 2' y 3 0 Street Number Direction Street Name city Zip Codeb A ` Ilt HOME or MAILING ADDRESS (if Different from Site Address) r � r/ Street Number Street Name / i I CITY STATE ZIP Oct Y � D PHONE #1 ExT. APN # LAND USE APPLICATION # SAN J 2021 ( ) E FAQ /N C PHONE #2 EXT BOS DISTRICT LOCATIO TSH pE q 'T/V TA Y CONTRACTOR / SERVICE REQUESTOR REQUESTOR1 cel U l t N a I Sa A A e / ( � CHECK If BILLING ADDRESS BUSINESS NAME ( V ll � ' V l U PHONE # EXT' JtQvv� a� e t)^� YvIcci 'ma c . Pas v o _ C) S'0 '? HOME or MAILING ADDRESS _ r 1 ( � `AX # I CITY O C �� b STATE C ZIP y s�0 y 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 : ,._T > L DATE : f/ 0 ' poC '" 7,02I PROPERTY / BUSINESS OWNER E OPERATOR I 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 : 1 COMMENTS: / O ✓ (�' C e � { y IYC� � J � � � � b �/ � c � W r` ( 4�1) vvj 7 (so 4) o \ - i v ,� , � .lr ! �::rh'ftc � ACCEPTED BY: J ' fes+ �\ i EMPLOYEE #: DATE: / ASSIGNED TO: / �I V EMPLOYEE #: DATE: / Q � " Date Service Completed (if already completed) : SERVICECODE: ~( g ,2 ' / [ P / E: � 0 Fee Amount: 00 Amount PaiW � - Ob Payment Date Payment Type V . 5 G-- I Invoice # Check # 132ge E 53 Received By : EHD 4&02-025 SR FORM (Golden Rod ) 07/17/08