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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Sre-oo q -o c( -7 T pe of Busin s or Property FACILITY ID # SERVICE REQUEST # CWVNER / OPERAT r1 f l i CHECK if BILLING ADDRESS E] FACILITY NAME - %i _ (( y - y f, S I BUSINESS NAM SITE ADDRESS f v D' Street Number L'Octlon ! l treet Name i Zi Code HOME or MAILING ADDRESS (If Different from Site Address) G� Street Number L(' l Street Name CITYT f'najr ZIP /} �/ PHONE #1 / EXT. 061) /5 / V APN # 5 0-0 LAND USE APPLICATION # PHONE #2 EXT. 1 BOS DISTRICT LOCATION CODE /1 CONTRACTdR / S&RVICE REQUESTOR REQUESTOR f 1 L iFCEI COMMENTS: - // NOV 2 ® 200 f; S.gN JONQUIN COUNT ENMRpNMENTAL } E TW OE;PARTMENT CHECK if BILLING ADDRESS BUSINESS NAM PH ON EXT. ASSIGNED TO: L E — HOME or MAIL NG ADDRESS Date Service Completed (if already completed): FAX# SERVICE CODE: ( 9E, c� P / E: Z3V R Fee Amount: 1y77 5 0-0 Amount Paid n CITY 7S2 A ZIP I/ Invoice # BILLING ACICNO LEDGEMENT: 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 applicatio nd hat the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, Standards, STATE d FE ERAL laws. APPLICANT'S SIGNATURE: Z DATE: / PROPERTY / BUSINESS OWNER ❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGEN� If APPLICANT is not the BiLuNG PARTY, proof of authorization to sign is required Tlite AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, 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. po.Y R/lEN 1 TYPE OF SERVICE REQUESTED: -T— E t T iFCEI COMMENTS: NOV 2 ® 200 f; S.gN JONQUIN COUNT ENMRpNMENTAL } E TW OE;PARTMENT ACCEPTED BY: D Lt EMPLOYEE #: U�,Z/ DATE: if ASSIGNED TO: L E EMPLOYEE #: 3S E -Z .) DATE: `I Z O Date Service Completed (if already completed): SERVICE CODE: ( 9E, c� P / E: Z3V R Fee Amount: 1y77 5 0-0 Amount Paid -lq • Q lJ Payment Date 1 J � Payment Type Invoice # Check # L7017? d Received By: EHD 48-02-025 SR FORM (Golden Rod) REVISED 11/17/2003