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SAN JOAQUI AUNTY ENVIRONMENTAL HEALTH SERVICE REQUEST r Property FACILITY ID # Type of Bus pp T um�l l Clyplihe Ji 5 0 A-11 I �aCii� �1-7�j- OWNER rRATOR �Ck I Box � �►� FAC 1 1 7 6'cl S� SISIESS rtht 1 IStreet Number Direction Street Name Wo -?r MAILING ADDRESS (If Different from Site Address) 14 -t tD Street Numt 1r�I IONE #1 EXT. APN # IZgl ) BE36 ©Z14, PHONE #2 EXT. ARTMENT SERVICE REQUEST # CHECK if BILLING ADDRESS Cit` S eet Name STATE ZIP -zt_ (,I LAND USE APPLICATION # BOS DISTRICT If`nNTR ACTOR TOR / SFRVICF REOUESTOR li!5111 IZ LOCATION CODE REQUESTOR SqN d 08 CHECK if BILLING ADDRESS %T�ne,I� Z1V'-V11V r Vt� EI�)� �Y BUSINESS NAME " CLEC I E Z008 ACCEPTED BY: PON # ` /� Exr, I ASSIGNED TO: EMPLOYEE #: ti vC/ HOME or MAILING ADDRESS Cw A(- ` FAX # r, P("-'8Fx Amount Paid -f ^, l ? Payment Type ) CITY Check # -7 -7 Jam' STATE 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 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 be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, Standards`, STATE and FEDERAL laws. �,cJ APPLICANT'S SIGNATURE: ► aya' V N DATE: PROPERTY/ BUSINESS OWNER OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT ❑ If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required Title AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, the owner or operator of the propego"ed at the above site address, hereby authorize the release of any and all results, geotechnical data and/or env ironmentaitis"0#1- �tlj information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same-A44A nrnvirlpri to me nr my renre.Centntive- DE/, r I TYPE OF SERV^ICCEE REQUESTED: SqN d 08 IF COMMENTS: %T�ne,I� Z1V'-V11V r Vt� EI�)� �Y FE (- rlwew CLEC I E Z008 ACCEPTED BY: EMPLOYEE#:T2 'i .''1'I"�1fl1641. `'/Irl I I' r ASSIGNED TO: EMPLOYEE #: DATE: 2 Date Service Completed (if already completed): SERVICE CODE: PIE: Fee Amount: Amount Paid -f ^, Payme Date /%r t 71 D Y Payment Type Invoice # Check # -7 -7 Jam' Received By: EHD REVISED SED 1111 11/171203 SR FORM (Golden Rod)