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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID # BUSINESS NAME SERVICE REQUEST # //-- v�L - C3 HOME or MAILINGDDRESS t5r,-��728 1 Lf OWNER / OPERATOR DATE: 712,- I/15 CITY STATE - ZIP \ ` EMPLOYEE #: CHECK If BILLING ADDRESS DATE: //"2-, f %f0 Date Service Completed (if already completed): SERVICE CODE: ,SGp(�I FACILITY NAME Fee Amount:' SITE ADDRESS Payment Date Payment Type Invoice # Check # `�� VI'\ (,a) =c.<§04tN m r Directio"'n' Street Name city Zip Code HOME or MAILING ADDRESS (If Different from Site Address) Street Number Street Name CITY STATE ZIP L��`. s PHONE #11 EXT. APN # LAND USE APPLICATION # PHONE #Z EXT, ( ) BOS DISTRICT LOCATION CODE CONTRACTOR It SERVICE REQUESTOR REQUESTOR CHECK If BILLING ADDRESS 74 C1L•d BUSINESS NAME PHONE # EXT. //-- v�L - C3 HOME or MAILINGDDRESS FAX# CC DATE: 712,- I/15 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 me or my business as identified on this form. 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, ST E d FEDERAL laws. APPLICANT'S SIGNATURE: DATE: —7 /4a / t PROPERTY / BUSINESS OWNER 110(' RATOR / MANAGER ElOTHER AUTHORIZED AGENT El If APPLICANT is not the ILLING 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 t0 me or my representative. PAYM NIT TYPE OF SERVICE REQUESTED: �/fi� ��yC ��Z`� 74 C1L•d COMMENTS: ' SAN JOAQUIN COUNTY ENVIROMENTAL HEALTH DEPARTMENT ACCEPTED BY: EMPLOYEE #: DATE: 712,- I/15 ASSIGNED TO: � '� Y�� EMPLOYEE #: DATE: //"2-, f %f0 Date Service Completed (if already completed): SERVICE CODE: ,SGp(�I P/E: Fee Amount:' Amount Paid Payment Date Payment Type Invoice # Check # `�� Received By: EHD 48-02-025 SR FORM (Golden Rod) 07/17/08