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SAN JOAQUgCOUNTY ENVIRONMENTAL HEALAEPARTMENT SERVICE REQUEST Type of Business or Property BUSINESS NAME �� PHONE# ExT. r FACILITY ID # SERVICE REQUEST # 44&t.LA�-46r 6IZ41006 S7WdyV CITY CITY STATE 11 A ZIP r Z 0. A-) alw &5--544 ENVIRONMENTAL HEALTH DEPARTMENT ACCEPTED BY: 9 W EMPLOYEE #: 35� ASSIGNED TO: % OWNER / OPERA OR -1 Date Service Completed (if already completed): -r ,9,GrC>ZYl �C CHECK If BILLING ADDRESS FACILITY NAME ' Payment Type ./ Invoice # Check # /, SITE ADDRESS W /j �f f?Q/Iq 1/ armLJ v� cna.�/I�� L Q �� Cly Street Number Direction treet Name city Zip Code HOME or MAILING ADDRESS (If Different from Site Address) Street Number Street Name CITY STATE ZIP PHONE #1 ( ) ExT• APN # LAND USE APPLICATION # PHONE #2 ( ) ExT• BOS DISTRICTLOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR /tnl/' ; J, . t�� CHECK If BILLING ADDRES r` (/ rT/V BUSINESS NAME �� PHONE# ExT. r HOME or MAILING ADDR SS_ FAX # c T - ) J^- CITY CITY STATE 11 A ZIP r Z 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 E and FEDERAL Ws. APPLICANT'S sIGNATU ('�� DATE:. rJ6 A� 1/., . 36 11 PROPERTY / BUSINESS _OWNERIZ��ffsERAT( AyAr LOTHER AUTHORIZED AGENTi� CAOPi t m'/NDI11t1A U if �_ fj/O�JI/ �� . IfAPPLICANT is not the BILLING PARTY, 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. TYPE OF SERVICE REQUESTED: tls J'" PAYMENT REGEIVED COMMENTS: AUG 2 9 2011 SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT ACCEPTED BY: 9 W EMPLOYEE #: DATE: ASSIGNED TO: % EMPLOYEE #: I Z12 2 DATE: Date Service Completed (if already completed): SERVICE CODE: HS, PIC � 'q? Fee Amount: � %�11 d Amount Paid ` Payment Date � u Payment Type ./ Invoice # Check # /, Re eived y: EHD 48-02-025 SR FORM (Golden Rod) REVISED 11/17/2003