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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID # SERVICE REQUEST # —1 r'�ou T (9J �A`�c [ U\QUrff)-5 OWNER / OPERATOk zip STATE CA CHECK If BILLING ADDRESS. iJl-1 �� FACILITY NAME n `` K— �fP1C��VZ SITE ADDRESS lar? kl agFH q�NrY Leo1 Leo ,{ f atrYe'e't1,Nu.ber Direction 1 i/^ Street Name &Z/1 z J city Zip Code HOME or MAILING ADDRESS (If Different from Site Address) EMPLOYEE #: l 6 Streal Number Date Service Complete (If already completed): Street Name CITY 2 STATE ZIP PHONE#1 EM. APN # USE APPLICATION # (409) 3COS-500 Payment Type Invoice # PROS PHONE#2 ( ) EaT. DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REOUESTOR IPY�,1 , M& TO �� I CHECK If BILLING ADDRESS❑ BUSINESS NAME PHONE# E'. — 2 /) •�'( !� HOME Or MAILIN ADDRESS box (VU FAX# I Wr ) 3( -ate CITY 1 o zip STATE CA 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 a that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, Standards, STATE an '•E ERAL laws. U-16-20 i �^ APPLICANT'S SIGNATURE: DATE: rr'� yy�.. y,`LL1-,, 1�0- p0 �� PROPERTY/ BUSINESS OWNER❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT- r„{�t{,td& V' PM -MD IfAPPLICANT is not the BILLING PAR iY 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 REOUESTEW iaf� COMMENTS: Noy �Fo �� y ehVOgQ�23 agFH q�NrY ACCEPTED BY: EMPLOYEE#: &Z/1 z J DATE: ' ASSIGNED TO: p EMPLOYEE #: l 6 DATE: !/ 2 Date Service Complete (If already completed): SERVICE CODE: 2 P E: , Q' Fee Amount: b 6 Amount Pa' GrO� Payment Date Z Payment Type Invoice # Check # 114T+ 466 //4!t 5 D Receive By: EHD 48-02-025 Mme• REVISED 11/17/2003 V"NC3M SR FORM (Golden Rod)