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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business r Property / <br />AGILITY ID # <br />PHONE ET. <br />S' <br />REDDEST # <br />e <br />al o M1 c(J�// — <br />::: <br />lwllwa <br />S�SERVICE <br />�r�jnl`�'�' ol/ [ <br />OWNER/OTOR <br />E] <br />CHECK If BILLING ADDRESS <br />FACILITY AME <br />/ <br />i <br />SITE ADDRESS <br />' <br />d <br />�Zin <br />Street Number <br />Direction <br />,/ <br />/ tre ame <br />O� Cit <br />Code / <br />HOME or MAILING <br />DDRES (If DI Brent from Site Address) <br />�'/ <br />Street Number <br />Street Name <br />CITY 0I, <br />L'o <br />\// <br />STATE /1 ZIP �r 2/ <br />Z— <br />PH�'O77NE#1 <br />T• <br />/"'' <br />APN # <br />LAND USE APPLICATION # <br />(Giyr, <br />(0 N <br />PHONE#Y <br />( ) <br />ExT <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR, C CHECK It BILLING ADDRESS <br />BUSINESS NAM <br />T✓ © V"'-- <br />PHONE ET. <br />S' <br />HOME Or MAILING DRESS <br />FAX# <br />CITY C.440 6L STATE ZIP <br />i <br />BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, <br />acknowledge that all site and/or project specific ENVIRONMENTAL. HEALTH DEPARTMENT hourly charges associated with this project <br />or activity will be billed to me or my business as identified on this form. <br />I also certify that I have prepared this application and that th •k to be rforLned will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards TE and F R I <br />APPLICANT'S SIGNATURE: ✓ - " DATE: �%� 'C'e JAlitt� <br />PROPERTY/ BUSINESS OWNERp P TOR/MANAGER ❑ OTHER AUED AGENT IJ <br />TfAPPG/CANT Is not th e BILLING PARTY proof of authorization to sign is required Title <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, the owner or operator of the property located at the <br />above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/sik assessment <br />information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the IS <br />provided to me or my representative. o;nN <br />TYPE OF SERVICE REQUESTED: <br />COMMENTS: <br />wtl trLS <br />ACCEPTED BY:Wom C EMPLOYEE M DATE: 2,I <br />ASSIGNED TO: ( G71 'V• EMPLOYEE#: 10��� DATE:('2I-�()'24 <br />Date Service Completed (if Date Service Completed (if already completed): SERVICE lel: FIE' I�Dl�l_OI FIE' I�D� <br />Fee Amount: I �j'1'�u Amount Paid C,`i i' Payment Date IQ 7,11 7 / <br />Payment Type /111,2 /I ,(G J I Invoice # I Check # ) � I I Received By: /1•//W <br />EHD 48-02-025 <br />REVISED 11/17/2003 <br />SR FORM (Golden Rod) <br />