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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID # COMMENTS: ..1.-�.S I�'�'�• t SERVICE REQUEST # CHECK If BILLING ADDRESS BUSINESS NAME l 5:+1 V;+u1 -ty'j eA .- a s OD7S56,- �P-S C -def,• a b` 6y' JO �jtJ 'lp $( t `oy1 G-�'Fiy HOME or MAILING DDRESS OWNER / OPE OR ACCEPTED BY: N ISS FAX # EMPLOYEE #: S S DATE: CHECK If BILLING ADDRESS FACILITY NAME CITY yn DATE: SITE ADDRESS G /I- PIE: Ll �2 0 2 Fee Amount: I S )-20 Street Number Direction Qt eet Payment Date 7 Payment Type HOME Or MAILING ADDRESS (If Different from Site Address) Check # 1773 Rece ed By: Street Number Street Name CITY STATE ZIP PHONE #1 EXT. -SI-13 APN # 0 Fs•7�(g036 LAND USE APPLICATION # (�) G-1 -SI-1 3 PHONE #2 EXT. ( ) BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR COMMENTS: ..1.-�.S I�'�'�• t r CHECK If BILLING ADDRESS BUSINESS NAME l 5:+1 V;+u1 -ty'j eA .- a PHONE # EXT. 0.W a DreQ -Frinw a b` 6y' JO �jtJ 'lp $( t `oy1 G-�'Fiy HOME or MAILING DDRESS ACCEPTED BY: N ISS FAX # EMPLOYEE #: S S DATE: ASSIGNED TO: CITY yn DATE: STATE ,_ zip 153 7 G /I- 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. 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 FE ERAL IaWS. APPLICANT'S SIGNATURE: DATE: PROPERTY/ BUSINESS OWNER ❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENTLO— C7:1� f t C j.? ✓� 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 ove site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment int to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as Soon as it IS available and at the same time it Is provided my representative. TYPE OF SERVICE REQUESTED: C 0 nS U G o - Sa '� ` C EHD 48-02-025 SR FORM (Golden Rod) 07/17/08 l� ry COMMENTS: ..1.-�.S I�'�'�• t "�i J`,7"�, �^� •rr� � 6� �1r�11�5 �o ��nt �ry''�o �'� �/q / f �` V� ri �i e� �' hk l �v.2 -Frdh� ►ti2;�V 5:+1 V;+u1 -ty'j eA .- a 0. �vo S' 0.W a DreQ -Frinw a b` 6y' JO �jtJ 'lp $( t `oy1 G-�'Fiy ACCEPTED BY: N ISS EMPLOYEE #: S S DATE: ASSIGNED TO: EMPLOYEE #: (f n DATE: Date Service Completed (if (ready completed): SERVICE CODE: 06) PIE: Ll �2 0 2 Fee Amount: I S )-20 Amount Pai ' Payment Date 7 Payment Type Invoice # Check # 1773 Rece ed By: EHD 48-02-025 SR FORM (Golden Rod) 07/17/08 l� ry