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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID # PHONE# ExT• SERVICE REQUEST# FA%# ( ) CITY <;�de IL P� STATE ca ZIP a(S Z. ( -L ACCEPTED BY: OWNER I OPERATOR CHECK If BILLING ADDRESS ASSIGNED TO: FACILITY NAME EMPLOYEE #: SITE ADDRESS Date Service Completed (if already completed): i SERVICE CODE: P 1 E: two Street Number 01 on Street Nama Payment Date CI ZipCode HOME Or MARIN(�O'.Aj>pRl� s (I(f�Diffe)t�ent from Site Address) Check # `� ZL - \ Wl "t/ C oSS C •� - Street Number Street Name CITY S'}oc v STrTE ZIP /i Z I 'Z A PHONE#1 APN# LAND USE APPLICATION# PHONE #2 Esr• BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR _ I. _ (- CHECK If BILLING ADDRESS M -Cd /_ A VV✓Y CNYJ Y` BUSINESS NAMELpr L j;✓ I/ ; �C e-1 F PHONE# ExT• HOME or MAILING` ADDRESS Z1'ZC( BnAeUosS C4- FA%# ( ) CITY <;�de IL P� STATE ca ZIP a(S Z. ( -L 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 b erformed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, Standards, STATE and FE I aws. APPLICANT'S SIGNATURE: 11 DATE: (-0 PROPEIVIY/ BUSINESS OWNER❑ OPERATOR/ MANAGER OTHER AUTHoruzED AGENT 11 If APPLICANT is not the BILLINGPARTY 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 Ike same time it is provided to me or my representative. A)r1L4&A — TYPE OF SERVICE REQUESTED: V t�I/tiL ( `�'` �/Lisl� levi I-wDei V46- COMMENTS: JUN 0 -SAN J0 ?022 y�rovioON S 00117'y ACCEPTED BY: EMPLOYEE#: DATE: ASSIGNED TO: EMPLOYEE #: DATE: Date Service Completed (if already completed): SERVICE CODE: P 1 E: two Fee Amount: 152 _ Amount Paid ls�f U Payment Date Payment Type&,-�, invoice # Check # `� Received By: EHD 48-02-025 SR FORM (Golden Rod) REVISED 11/17/2003