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SAN JOAQUII JUNTY ENVIRONMENTAL HEALTH PARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID # SERVICE REQUEST # 1.'N D, A -J R a C 62 FAX # SIr2c�o 3 i'v OWNER / OPERATOR NOV 16 2011 f _ / \ 1 1-10 P 1V V 1 �' /1 � r f CHECK if BILLING ADDRESS FACILITY NAME T- SITE ADDRESS 32 0 4, I L► 'I' A N I L) I EMPLOYEE #:3Z DATE: r ( C & ( f Street Number Direction Street Name DATE: C Zi Code OME r MAILING ADDRESS (If Different from Site Address) PIE: t (e®/ Ll G I v.f i- n L t Street Number ?,,00 Street Name CITY Mor , JT STATE / �3 ZIP , L4 PHONE #'I EXT. APN # LAND USE APPLICATION # PHONE V EXT• cj BOS DISTRICT LOCATION CODE 03 CONTRACTOR / SERVICE REQUESTOR REQUESTOR CHECK If BILLING ADDRESS BUSINESS NAME PHONE # EXT. HOME or MAILING ADDRESS FAX # CITY 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 roe 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 I WS. APPLICANT'S SIGNATURE: LA:0 DATE: l PROPERTY / BUSINESS OWNERS 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 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: O O Y L: -tJ C'N C—C COMMENTS: P.F''r..' .. NOV 16 2011 SAN JOAQUIN COUNTY EWRONMENTAL HEALTH DEPARTMENT ACCEPTED BY: C i VE t 4,V EMPLOYEE #:3Z DATE: r ( C & ( f ASSIGNED TO: EMPLOYEE M 14 2--o DATE: Date Service Completed (if already completed): SERVICE CODE: S 2-2- PIE: t (e®/ Fee Amount: IC3 r1 S, tn) Amount Paid I ?,,00 Payment Date (` 1 Le t' Payment Type G Invoice # Check # �� Received By EHD 48-02-025 SR FORM (Golden Rod) REVISED 11/17/2003