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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property ,r FACILITY ID ID # SERVICE REQUEST # �a5 MAR g 2011 r' T S/�QD (po�%0 L PHONE EXT_ l u OWNER/ OPERATOR , 7 — Z" t (._ F;2 f q /P �� �T gU t f C CHECK if BILLING ADDRESS 12- LJ� FACILITY NAME //', FAX# SITE ADDRESS DATE: 3 / SERVICE CODE: O x P 1 E: .13 p Street Number Direction Street Name City Zip Code HOME or MAILING ADDRESS (If Different from Site Address) 1''IeC% 7— c L e C >�`T C(/ Street Number Street Name CITY ---- -? A c i STATE Zip C---1 ':�; S�3 ' PHONE #1 EXT. APN # LAND USE APPLICATION # (Zccr) 9 3 Z- ' - PHONE #2 E.T. � �3 - 33 )3 BOS DISTRICT LOCATION CODE (z-�� ► CONTRACTOR / SERVICE REQUESTOR REQUESTOR (,O—((l ,r CHECK If BILLING ADDRESS E] 111M MAR g 2011 BUSINESS NAME J I / PHONE EXT_ l u ACCEPTED BY:EMPLOYEE / wc• 7 — Z" HOME or MAILING ADDRESS 1 ASSIGNED TO: ` u FAX# CITY \ �vr DATE: 3 ! STATE ZIP BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknrn\ ledge 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. APPLICANT'S SIGNATURE: - / ,, S o -ti ti h_ DATE: PROPERTI' / I3LISINESS OWNFR OPFRATOR / MANAGER ❑ OTHER AUT110RIZED AGENT ❑ If APPLICANT is nol the BILLING PARTF proof of authorization t0 sign is required 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: uST %f�0�/%_ V) COMMENTS:tir 111M MAR g 2011 SAN JOAQUIN COUNTY ENVIROMEN-TM HEALTH DEPARTMENT ACCEPTED BY:EMPLOYEE / wc• #: DATE:.3 ASSIGNED TO: ` u EMPLOYEE #: �vW76 DATE: 3 Date Service Completed (if already completed): SERVICE CODE: O x P 1 E: .13 p Fee Amount: 3(o�OG Amount Paid i Payment Date 3 ( 8 5/ Payment Type Invoice # Check # 2l Received By: EHD 48-02-025 SR FORM (Golden Rod) REVISED 11/17/2003