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A"1rii\V1t1r1L`1\1HL1117— lLIrl EYAIt1INIENT SERVICE REQUEST Type of Business or Property FACILITY ID# SERVICE EQUEST L�)r .R . OWNER/ OPERATOR �. CHECK If BILLING ADDRESS FACILITY NAME � •� �� SITE ADDRESS �l `J 1 � , C� Street Number Direction Street Name J Cit Zi Code HOME Or MAILING ADDRESS (If Different from Site Address) Stree Street Name CITY STATE ZIP PHONE#1 T• APN# LAND USE APPLICATION# PHONE#2 ExT. BOS DISTRICT LOCATION CODE ( ) CONTRACTOR/SERVICE REQUESTOR REQUEST t CHECK if BILLING ADDRESS El BUSINESS NAME ; i P N Ext. -�3`��- HOME Of MAILING ADDRESS Rib 3 CITY l• STATE (� /� ZIP / w 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,Standards,STATE and FEDERAL APPLI.CANT'S SIGNATURE: DATE: PROPERTY/BUSINESS OWNER[] OPERATOR/MANAGER ❑ rER AUTHORIZ D AGENT r YAPPLICANT isnot theBIIJ"GPARTY proof of authorization to sign is require Title ��//111 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. u S 7— , TYPE OF SERVICE REQUESTED: COMMENTS: PAYMENT RECEIVED AUG 2 6 2010 SAN JOAQUIN COUNTY ENVIRONMENTAL EPARTMENT ACCEPTED BY: C_.f t �] EMPLOYEE#: Q 2-( DA7p; ASSIGNED TO: Al �T J �-♦�t.tS EMPLOYEE#: L �b DATE: Date Service Completed (if already completed): SERVICE CODE: ' y PIE: 23O, Fee Amount: ' Amount Paid 5C-k'C-L 3 � r Payment Date Payment Type C a Invoice# Check# �`J[ 9S �j 2,-2,5 Received By: �✓� EHD 48-02-025 ca-,Q- REVISED a-,Q REVISED 11/17/2003 6 :: 6d [i'Rod)