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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID # 'r^vvl SERVICE REQUEST # SCG e � EMPLOYEE #: I 1 S3 BUSINESS ASSIGNED TO: 12- OWNER / OPE ATOR Date Service Completed (if already completed): HOME Or MAILING ADD SS CHECK If BILLING ADDRESS ❑ 11 b G S FACILITY iME Kq AAr �1, / tel/ r Invoice # SITE ADDR/Ell S �(1{ jy� ��YJu/b CITYSTATE �2- I < j1 Gi r, r U l G4- 7 (� C) Direction Street Name Cit/ Zi Code 7 HOME or MAILING ADDRES (If ifferent from Site Address) U VIS Yl C� Street Number Street Name CITY �f, STATE ZIP C; (11) PHONE #1 EXT. APN # LAND USE APPLICATION # (z 6 y) I ,Y60 PHONE #2 EXT. (.-32- BOS DISTRICT LOCATION CODE (� ) CONTRACTOR / SERVICE REQUESTOR RE(1UESTOR ❑ 'r^vvl CHECK If BILLING ADDRESS G n EMPLOYEE #: I 1 S3 BUSINESS ASSIGNED TO: PHONE # EXT. V i �� Date Service Completed (if already completed): HOME Or MAILING ADD SS P E: l,1103 FAX # b G S Payment Date 3 3 2-2-- r Invoice # ( )w CITYSTATE ZIP ) 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 prQject 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, ST E a FEDERAL laws. APPLICANT'S SIGNATURE: DATE:� I� PROPERTY / BUSINESS OWNER ❑ PE OR /MANAGER OTHER AUTHORIZED AGENT ❑ If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required Tule AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, 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. PAVMENT TYPE OF SERVICE REQUESTED: moo( RECEIVED COMMENTS: 14 MAR 0 3 2022 SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT ACCEPTED BY: �pp EMPLOYEE #: I 1 S3 DATE: 313/2L ASSIGNED TO: EMPLOYEE #: DATE: Date Service Completed (if already completed): SERVICE CODE: 061 P E: l,1103 Fee Amount: Amount Paid G S Payment Date 3 3 2-2-- Payment Type Invoice # Check # Received By: EHD 48-02-025 SR FORM (Golden Rod) REVISED 11/17/2003