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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Ty a of Busi er opee FACILITY ID# SERVICE REQUEST# 6-2 q CHECK If BILLING ADDRESS FACILITY NAME 1� �Lj-.JSlreet Number I\\}n St et Name ��C�CC�aT.�[� Z,P Cone HOME Or MAILING ApQpRESS (If Different from Site Address) S0. — St eet Number Street Name CITY STATE ZIP PHONE#1 Em' APN# LAND USE APPLICATION# Z9 u R4 6 S03 PHONE G" BOS DISTRICT LOCATION CODE L 23 �t 35 CONTRACTOR/ SERVICE REQUESTOR REQUESTOR CHECK if BILLING ADDRESS O BI�SINESS NAME PHONE# EXT. HOME or MAILING ADDRESS FAX# KnJ C-P• u g ( ) CITY STATE ZIP z , 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 the a work to be performed will be done in accordance w'th all SA JOAQUIN COUNTY Ordinance Codes,Standards TE and F' laws. APPLICANT'S SIGNATURE DATE: / PROPERTY/BUSINESS OWNER❑ ERATOR/MANAGER ❑ HER AUTHORIZED AG IfAPPLIC9NT is not th BILLING PAx7T proof of authorization to sign is requ red Title AUTHORIZATION TO RELEAS 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: /V2o!/Z �l ACCEPTED Y: hkw EMPLOYEE M DATE: ASSIGNED TO: EMPLOYEE M DATE: Date Service Completed (if already completed): SERVICE CODE: ?fL - P I E -L Fee Amount: Amount Paid Payment Date Payment Type dam ' Invoice# Check# Received By: EHD 48-02-025 SR FORM(Golden Rod) REVISED 11/17/2003