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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID # . SERVICE REQUEST # Go"s '5 PHONE# ExT. ( oq) 633 HOME or MAILING ADDRESS S35' Wt 1'oa%I r OWNER / OPERVar, ^ CHECK if BILLING ADDRESS FACILITY NAME I ! C� Ila. HEALTH DEPARTMENT i n EMPLOYEE #: v DATE: ZI SITE ADDRESS a ,,, q S, Man EMPLOYEE M Street Number Direction Street Name City Zip Code HOME or MAILING ADDRESS (If Different from Site Address) P I E:� Fee Amount: 2 Amount Paid CT-DPayment Street Number Street Name Invoice # CITY STATE ZIP PHONE #1 EXT. (dm) 41Ga - 17&1-11t APN # LAND USE APPLICATION # - b PHONE #2 EXT. ( ) BOS DISTRICT LOCATION CODE / CONTRACTOR / SERVICE REQUESTOR REQUESTOR - t � e EUI \ (A,t V CHECK If BILLING ADORES BUSINESS NAME •ie- RECEIVED PHONE# ExT. ( oq) 633 HOME or MAILING ADDRESS S35' Wt 1'oa%I r FAX # (moi) VIPl-(A31a CITY / _ STATECA ZIP C� Sabs 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, STATE and FEDERAL laws. APPLICANT'S SIGNATURE:Nk"� i ' ! DATE: /I- vZ 7- 67 PROPERTY/ BUSINESS OWNER ❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT Rt 5�eV V t e- CA O r cl LY A—. rr ' 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 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. EHD 48-02-025 SR FORM (Golden Rod) REVISED 11/17/2003 i HT IV11-1v e TYPE OF SERVICE REQUESTED: RECEIVED COMMENTS: rvov 2 7 2007 SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT ACCEPTED BY: EMPLOYEE #: v DATE: ZI ASSIGNED TO: (/ EMPLOYEE M DATE: Date Service Completed (if already completed): SERVICE CODE: P I E:� Fee Amount: 2 Amount Paid CT-DPayment Date (� `ZZ Payment Type Invoice # Check # Lf Received By: .a o`0 EHD 48-02-025 SR FORM (Golden Rod) REVISED 11/17/2003