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SAN JOAQAOUNTY ENVIRONMENTAL HEALTI-10PARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID # SERVICE REQUEST # S TNc• PHONE # S c> Sk00-7o-30C- FAX # (q Ana CITY OWNER / OPERATOR ZIP 1111�0 'w ACCEPTED BY: CHECK If BILLING ADDRESS FACILITY NAME EMPLOYEE #: SITE ADDRESS ASSIGNED TO: KAAPCT Ec-4k- IR to Street Number Direction Street Name SERVICE CODE: I x Cit Zi Code HOME or MAILING ADDRESS (If Different from Site Address) 3� U ---- Amount Paid 3'j0, 6C> Street Number /Z/7 Street Name CITY STATE ZIP PHONE #t EXT. Received By:%� APN # LAND USE APPLICATION # ( ) -70 0 I $0 - 3 ( - PHONE #2 EXT. BOS DISTRICT LOCATION COD ( > oo 3 11444,i CONTRACTOR / SERVICE REQUESTOR REQUESTOR CHECK If BILLING ADDRESS BUSINESS NAME FLS 6 1VZ,�1,M6N crQ•L S TNc• PHONE # S Exr. ("?S•Zz3 HOME or MAILING ADDRESS 'Z'au►1NE 7 E ��• FAX # (q • 5210 CITY STATE C -A ZIP 1111�0 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, STATE and FEDERAL laws. APPLICANT'S SIGNATURE: �' --Rx�- DATE: % I4 PROPERTY/ BUSINESS OWNER ❑ OPERATOR / MANAGER ❑ OTHER AUTHORIZED AGENT �tA-AM "6*—i If APPLICANT 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 t0 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. TYPE OF SERVICE REQUESTED: COMMENTS: AUG i2 20 -" JD'4 HE44Tf �0�CArr 'w ACCEPTED BY: A4 , (�[� ✓fid/ EMPLOYEE #: DATE:I ASSIGNED TO: ✓1 EMPLOYEE #: DATE: Date Service Completed (if already completed): SERVICE CODE: I x PIE: Z3u Fee Amount: 3� U ---- Amount Paid 3'j0, 6C> Payment Date /Z/7 Payment Type Invoice # Check # �� 3,� Received By:%� EHD 48-02-025 SR FORM (Golden Rod) 07/17/08