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SAN JOAQU*OUNTY ENVIRONMENTAL HEALTAPARTMENT SERVICE REQUEST Type of Business or Property kk t f -j'"� r' FACILITY ID # �P SERVICE REQUEST # PHONEC14-3 Go I&P3 $VG-Ama�2(40 MAR 1 1 2009 OWNER/ OPERATOR CHECK if BILLING ADDRESS CITY �1�ju /j� -7 STATE C 4 ZIP 1-5 FACILITY NAME SITE ADDRESS 1tree.ber ACCEPTED BY: EMPLOYEE #: l DATE: //� Direction EMPLOYEE #: �i Street Name Date Service Completed (if already complete Ci Zi Code HOME or MAILING ADDRESS (If Different from Site Address) Fee Amount: ` Amount Paid31 Street Number Street Name CITY Invoice # STATE ZIP PHONE t#1 EXT. (2 f cc63-'2--Y— C� 1 �.--' APN #'� �J ..Z- — `Y O C. LAND USE APPLICATION # PHONE #2 EXT. ( )–�71 BOS DISTRICT LOCATION CODE iE" — CONTRACTOR / SERVICE REQUESTOR REQUESTOR l�I II C y�, �� r ' I tc—+.�/'� p/ [�A^ / /\\ \ kk t f -j'"� r' CHECK if BILLING ADDRESS® BUSINESS NAME n � .� �` jn �$/ PHONEC14-3 r -3c.) G ' HOME or MAILING ADDRESS;1 MAR 1 1 2009 FAx # 1'7 CITY �1�ju /j� -7 STATE C 4 ZIP 1-5 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, S and D laws. APPLICANT'S SIGNATURE: _ DATE: V�� PROPERTY / BUSINESS OWNER OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT ❑ IfAPPLICAArT is not the BILLING 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 to me or my representative. MAN/ TYPE OF SERVICE REQUESTED: ( � n ► ►vIGIV I R CEIVEn COMMENTS: MAR 1 1 2009 SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT ACCEPTED BY: EMPLOYEE #: l DATE: ASSIGNED TO: / EMPLOYEE #: �i DATE: Date Service Completed (if already complete SERVICE CODE: P 1 E: `Z -3t Fee Amount: ` Amount Paid31 �. b Z) Payment Date 3 fI ( a 17 Payment Type Invoice # Check # 0 2 Received By: EHD 48-02-025 SR FORM (Golden Rod) REVISED 11/17/2003