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� � A SAN J(�AQUIIST COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Propf Ay FACILITY ID # SERVICE REQUEST # HOME Or MAILING ADDRESS Lo CDto&MENT, HEALTH 12000 .?�- Ybv F # OWNER / OPERATOR j lsll(l H�LTN CHECK if BILLING ADDRESS EMPLOYEE #: DATE: ASSIGNED TO: CACAfff FACILITY NAME i CWo c J �) � � 101) [�0 �J� SITE ADDRESS Is Date Service Completed (if already Completed): V LI c PajJ/O, Street Number Direction ° Slt�reet Name Ci ZI Code HOME Dr MAILING ADDRESS (If Different from Site Address) Received By: n J 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, \ CHECK If BILLING ADDRESS BUSINESS NAMEP COMMENTS: (AZ EXT. E# HOME Or MAILING ADDRESS Lo CDto&MENT, HEALTH F # CITY n� pfi STATE ZIP L S7 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, SZ FEDERAL laws. APPLICANT'S SIGNATURE: ��l DATE: d; PROPERTY / BUSINESS OWNER ❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT IfAPPLtCANT 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. TYPE OF SERVICE REQUESTED: 'PAY1.-,\/eunig��tuvv go COMMENTS: (AZ APR 2 0 2009 APR 2 0 2009 1 b q b S.—ca.,, b`-• CDto&MENT, HEALTH DApU1N SAEN�IRDEP R1�iEMIT15ER1IICES C -- \\ ofl�o� C o` D S H�LTN ACCEPTED BY: EMPLOYEE #: DATE: ASSIGNED TO: CACAfff EMPLOYEE #: DATE: Date Service Completed (if already Completed): SERVICE CODE: P ! E: Fee Amount: S '' Amount Paid ° Payment ate U Payment Type Invoice # Check # Received By: EHD 48-02-025 SR FORM (Go14 Rod) REVISED 11/17/2003