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SAN JOAQUI' 'OUNTY ENVIRONMENTAL HEAL*EPARTMENT SERVICE REQUEST Typ o $usiness or Property CHECK If BILLING ADDRESS FACILITY ID # SERVICE REQUEST # •FA MEN j��GEIVED n'� , 4 2 SAN JOAQUIN COUNTY ENVIRONM TA oao3y3o s2oo STATE e-� ZIP p�205 *ALT DA - ASSIGNED TO: L OWNER/ OPERATOR EMPLOYEE #: 11 � I (-C Q Pe ccs U 5 G r o L -1 - CHECK If BILLING ADDRESS FACILITY NAME V 1 0- 5P cn- Vrr� e 5% /M CL- v- N ct✓ Fee Amount: -2,7 G SITE ADDRESS T Street Number Direction G � UCL p� a -mem � � Invoice # c C/l 6 � / 5 �Ci �N C� �j ?.5 /� Zi Code HeMEeFMAILING ADDRESS (If Different from Site Address) IStreet P f N /- c G O Number Street Name CITY y- / STATE ZIP p 'rte PHONE #1 ( ) EXT. APN # LAND USE APPLICATION # PHONE #2 ( ) EXT. BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR CHECK If BILLING ADDRESS BUSINESS NAME �T PHONE# EXT. ( ) *6/—C,33-7 HOME or MAILING ADDRESS z 3 Sc— t(J MEN j��GEIVED n'� , 4 2 SAN JOAQUIN COUNTY ENVIRONM TA FAX# 'oil) / - 634-2 CITY 5 7--Z U C I4 Zi / STATE e-� ZIP p�205 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 tlus application and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, Standards, STATE and DERA laws. APPLICANT'S SIGNATURE: DATE: PROPERTY/ BUSINESS OWNER ❑PERATOR / MA/A R ElOTHER AUTHORIZED AGENT S 2 �P S % v ` /V S! . If APPLICANT Is not12e4BILLIAGPAR TY proof of authorization to sign is required Ti rte 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: .5 'p �+ z. /cL r e N COMMENTS: V- e- c q 4,w, VFw tn�A� tb �t4i .� O / V ry e /V 7., 0 �v � MEN j��GEIVED n'� , 4 2 SAN JOAQUIN COUNTY ENVIRONM TA ACCEPTED BY: EMPLOYEE #: *ALT DA - ASSIGNED TO: L EMPLOYEE #: DATE: Date Service Completed (if already completed): SERVICE CODE: P I E: i7 Fee Amount: -2,7 G Amount Paid ar� l Payment Date Payment Type Invoice # Check # 2c\q Received By: EHD 48-02-025 SR FORM (Golden Rod) REVISED 11/17/2003