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SAN JOAQUI•OUNTY ENVIRONMENTAL HEALTH DI ARTMENT SERVICE REQUEST Type of Business or Property CHECK If BILLING ADDRESS 13 �J BUSINESS NAME FACILITY ID # SERVICE REQUEST # or MAILING ADDRESS Yd 4 5(e„., FAX# 16)C a), 75 J 1 D- 5 -*s ASSIGNED TO' EMPLOYEE #: oo Date Service completed (V already completed): OWNER / OPERATOR _ PIE: l Fee Amount:I v� r CHECK If BILLING ADDRESS FACILITY NAME Payment Date Payment Type SITE ADDRE Check # Received By: COL&.14Y) C.tt�b Q l�urA i !PJC Street Number Direction Street Name city Zi Cude HOME or MAILING ADDRESS (if Different from Site Address) Yo lr „ H (�jy� Street Number Street Name CITY STATE ZIP 8 PHONE #1 EXT. APN # LAND USE APPLICATION # 3 9 3.3 PHONE #2 ( ) EXT, BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR (^ CHECK If BILLING ADDRESS 13 �J BUSINESS NAME hF 'OM� COU PHONE# EXT. 2.s 3Q3- 3 i .73HOME or MAILING ADDRESS Yd 4 5(e„., FAX# ACCEPTED BY: C STATE ZIP 9f—J S Y 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 wail be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, Standards, STATE and FEDE laws. APPLICANT'S SIGNATURE: DATE: PROPERTY I BUSINESS OWNER lau OPER. / NAGER ❑ OTHER AUTHORIZED AGENT ❑ D Cy K c, '» If APPLICANT is not the BILLI14G 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 t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon NS It Is available and at the same time i to me or my representative.Y/, _ TYPE OF SERVICE REQUESTED: Cj I r/--, —, �� `�kF COMMENTS' SAN JOAQ 2015 hF 'OM� COU CTS ACCEPTED BY: EMPLOYEE #: DATE: r/ _ ASSIGNED TO' EMPLOYEE #: DATE: Date Service completed (V already completed): SERVICE CODE: O PIE: l Fee Amount:I v� r Amount Paid Payment Date Payment Type Invoice f Check # Received By: EHD 48-02-025 SR FORM (Golden Rod) 07/17/08