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SAN JOAQUIN "OUNTY ENVIRONMENTAL HEALTH'�EPARTMENT SERVICE REQUEST Type of Business or Property CHECK If BILLING ADDRESS FACILITY ID # SERVICE REQUEST # ` HOME Or MAILING ADDRESS a.S3 S l.J t �rQM O FAX# l- t'o 3 q,2 CITY 1 _ lr OWNER / OPERATOR / _ \ , CHECK If BILLING ADDRESS r �G� n ' ' SAN JOAQUIN COUNTY ENVIRONM FACILITY NAME i. or,(.t.l �e� ' r cv � o< 1!7 �J L �i YEA � r i r�-& 3 SITE ADDRESS ;L � �;\"a' v �fl d✓J Stre t um er Direction e a Ci Zi Code Code HOME Or MAILING ADDRESS (If Different from Site Address) DATE: Street Number Street Name CITY j y�.c`�- STATE ZIP PHONE #'I EXT. Amount Paid rT , 61) APN # ent Date 31116 g LAND USE APPLICATION # Gaj (46-&433 Check # 2 9 b Received By: PHONE #2 EXT. ( ) BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR I iu ale - CHECK If BILLING ADDRESS BUSINESS NAME lir' Con�rc:c�or5. �nG COMMENTS: PH NE# EXT. ( HOME Or MAILING ADDRESS a.S3 S l.J t �rQM FAX# l- t'o 3 q,2 CITY 1 _ lr STATE C? pt ZIP 95a p 5 - BILLING 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, Standar STATE and FEDERAL laws. APPLICANT'S SIGNATURE fz&%YDATE: - (o -7C) 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, 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 time it is provided to me or my representative. TYPE OF SERVICE REQUESTED: COMMENTS: PAYMENTRECEIVED MAK - 7 2uU8 SAN JOAQUIN COUNTY ENVIRONM ACCEPTED BY: EMPLOYEE #: DAT . EPARTM ASSIGNED TO: I_ EMPLOYEE #: D� DATE: Date Service Completed (i already completed): SERVICE CODE: PIE: Fee Amount: -?a Amount Paid rT , 61) Pay ent Date 31116 g Payment Type - Invoice # Check # 2 9 b Received By: EHD 48-02-025 SR FORM (Golden Rod) REVISED 11/17/2003