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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH MEPARTMENT SERVICE REQUEST Type of Businessor Property C s s.4. A CHECK If BILLING ADDRESS® FACILITY ID # 4 SERVICE REQU ST # PHONE# n � aVT) HOME or MAILING ADD/R-ES�STJ9Ya 7 T��E-7M/ C Pr•T/� ^,I (J t5 FAx Ll 1 n — 9 9 - F, c)©�9 OWNERIOPERATOR p r. RHtf r/A/ r?f- K 011 Va I_1 Vl ,7 CHECK If BILLING ADDRESS c7 DATE: FACILITY NAME r ✓T a"" L its y InAR„? c��w�� SERVICE CODE: q� SITE ADDRESS p U u !-Street Fee Amount: ' ��mJ� ✓ � S7 -G/ „70N q ON Number Direction Sr et Name cityZip�od`ee HOME or MAILING ADDREESSSf�(If Difffreerent from Site ddress) �Y 6 7 C'" MG r`-�” Streel Number Street Name CITY S7 -0C JFO/,v h STATE CR ZIP q�"l.L 12, PHONE#11 EXT. (M) 1? 5*- (-5-1-1 S' APN # LAND USE APPLICATION # (HONE#Z I �— ��C� Ex . BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REOUESTOR p I �LJI[ i7 wl /V D FFn s ! )��I'J CHECK If BILLING ADDRESS® BUSINESS NAME f�rN -T a 1� y /nyl w -r PHONE# n � aVT) HOME or MAILING ADD/R-ES�STJ9Ya 7 T��E-7M/ C Pr•T/� ^,I (J C i r FAx Ll 1 n — 9 9 - CRY 7iO ! 3 AI STATE (r r- ZIPL x212 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 ,yr}d FEDEpAL laws. I ' APPLICANT'S SIGNATURE. - yl/�/i/lihL.L/k (lTt�,'�r,• I DATE: / q b `f PROPERTY/ BUSINESS OWNER CJ 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, 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 the Same tifrtiiiel�prQvided to me or my representative. A/(DQE' TYPE OF SERVICE REQUESTED: / Iz m 100 fay VFD COMMENTS: • SqN 1 p 2ON HEA`IVV ROMf COON h 1) P441 ACCEPTED BY: EMPLOYEE#:DATE: I� ASSIGNED TO: EMPLOYEE M iN DATE: Date Service Completed (if already Completed): SERVICE CODE: q� PIE: Fee Amount: ' Amount Paid 3375-- U D Payment Date ,szct l Payment Type Invoice # Check # 20 Z Received By EHD 48-02-025 SR FORM (Golden Rod) 07/17/08 Im