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r� L, SAN JOAQ* AUNTY ENVIRONMENTAL HEALTO TARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID # SERVICE REQUEST # CHECK if BILLING ADDRESS 00 2 OWNER i OPERATOR CHECK if BI W NG ADDRESS ❑ FACILITY NAME PHONE# EXT. SITE ADD Sa r LA. -S � /may TL�z -q 111 HOME or MAILING ADDRESSFAX# � evd-r � U Street Number �1^ Direction iStreet Name - ` ' I Fee Amount: 2 Cv y C' Zi Code HOME or MAILING ADDRESS (If Different from Site Address) Invoice # Check # 5 3 Street Number Street Name CITY STATE ZIP PHONE #1 EXT. APN # LAND USE APPLICATION # PHONE #2 ExT. ( ) BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR /ti ' " CHECK if BILLING ADDRESS ( J U L 10 U l! d. SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT BUSINESS NAME EMPLOYEE M PHONE# EXT. !� r LA. -q 111 HOME or MAILING ADDRESSFAX# � evd-r � SERVICE CODE: ) . z- 1501r�71Tz�T 49 Fee Amount: 2 Cv STATE /� ZIP 9 L� `� Payment Type Invoice # •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: �.I-1 t�r.�1(/�11 DATE: "7- fJ PROPERTY / BUSINESS OWNER ❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT Y- nQ M CA. A Gc PA IfAPPLiCANT is not theBLELINGPARTY, proof of authorization to sign is required/ ,0 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.��j"( • TYPE OF SERVICE REQUESTED: r' Rear-- �� - F -U coetmem: J U L 10 U l! d. SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT ACCEPTED BY:Lu EMPLOYEE M DATE:It n 1A ASSIGNED TO: V EMPLOYEE M IWO DATE: Date Service Completed (if already completed): SERVICE CODE: q PIE: Fee Amount: 2 Cv Amount Paid d p Payment Date 0 Payment Type Invoice # Check # 5 3 Received By: EHD 48-02-025 SR FORM (Golden Rod) REVISED 11/17/2003