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SAN JOAQUIVOUNTY ENVIRONMENTAL HEALT*PARTMENT SERVICE REQUEST Type of Business or Property CHECK If BILLING ADDRESS k &k& r FACILITY ID # SERVICE REQUEST # PHONEY EXT. 2 413 - 30CC) HOME Or MAILING ADDRESS V�nx ss 1 ACCEPTED BY: JoZ 590 6Z3 OWNER/ OPERATOR ASSIGNED TO: E] DATE: CHECK if BILLING ADDRESS FACILITY NAME . SERVICE CODE: P P 1 E: 2 0 SITE ADDRESS �' C) to Amount Paid �� ntw Payment Sil Ii �a,vi l�I l�h—Ciit (J Payment Type /x-269 _/�Zi Street Number Direction Street Name Re eived By: Code HOME or MAILING ADDRESS (If Different from Site Address) I v Street Number Street Name CITY �� O � STATE C A ZIP �"'i CicJ Ise) PHONE #1 EXT. APN # LAND USE APPLICATION # (40)2-2-6S1 PHONE #2 EXT• BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR /! n -9A. CHECK If BILLING ADDRESS k &k& r BUSINESS NAME r ca,h Pe 14e COMMENTS: PHONEY EXT. 2 413 - 30CC) HOME Or MAILING ADDRESS V�nx ss 1 ACCEPTED BY: FAX# (� ( ) lei -3 3003 CITYS ivcy STATEOfl ZIP /,5 ,� ^s BILLING ACKNOWLEDGEMENT: 1, 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, TATE a ERAL laws. APPLICANT'S SIGNATURE: DATE: PROPERTY / BUSINESS OWNER❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT iv c,QC+ maoaaer If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required -.1 Title 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. TYPE OF SERVICE REQUESTED: 05,T 2AYMENT COMMENTS: RECEIVLU JUN 2 6 2009 SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT ACCEPTED BY: EMPLOYEE #: 19h DATE: ASSIGNED TO: EMPLOYEE#: L /_ DATE: Date Service Completed (if already completed): SERVICE CODE: P P 1 E: 2 0 Fee Amount: ��5,'` Amount Paid .�3 Payment Date Payment Type Invoice # Check # 5-a1f. — Re eived By: EHD 48-02-025 SR FORM (Golden Rod) REVISED 11/17/2003