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SAN JOAQU*OUNTY ENVIRONMENTAL HEALTWEPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID # 1 " iT Tyr i SERVICE REQUEST # BUSINESS NAME g , . T -N TATn1tTgC E 201A u r- 1, 2 4 2008 PHONE# EXT. 1 ) 3ii-23 a HOME Or MAILING ADDRESS SrS�j � � ^ E- HC,U S I OWNER /OPERATOR A,�I F C1 CHECK If BILLING ADDRESS❑ FACILITY NAMEIC STATE C P1 ZIP Cl 1 SITE ADDRESS 19910 (2— DATE: ASSIGNED TO:l C J Street Number Direction Street Name City Zip Code SERVICE CODE: tG�� Plb `Z3ts� Fee Amount: �� s , HOME or MAILING ADDRESS (If Different from Site Address) I S 0)— Payment Date Y r A< Ah, Street Number Invoice # Street Name CITY STATE ZIP PHONE #1 EXT. ( ) APN # LAND USE APPLICATION # PHONE#2 ExT. BOS DISTRICT LOCATION CODE CONTRACTOR/ SERVICE REQUESTOR REQUESTOR All ' T r^ �� N � i`"' Z N CHECK if BILLING ADDRESS EY 1 " iT Tyr i S 1 to e5 BUSINESS NAME g , . T -N TATn1tTgC E 201A u r- 1, 2 4 2008 PHONE# EXT. 1 ) 3ii-23 a HOME Or MAILING ADDRESS SrS�j � � ^ E- HC,U S I Ax # ) CITY (� + `� — N F—1y TC) STATE C P1 ZIP Cl 1 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 th t e work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, Standards, STATE and F WS. APPLICANT'S SIGNATURE: DATE: PROPERTY / BUSINESS OWNER ❑ OPE TOR / MANAGER OTHER AUTHORIZED AGENT ❑ If APPLICANT is not the BiLLINGPARTY, 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 tune it is nrnvided to me. or my representative. TYPE OF SERVICE REQUESTED: PAY HENT COMMENTS: u r- 1, 2 4 2008 SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT ACCEPTED BY: M , N (�( EMPLOYEE #: DATE: ASSIGNED TO:l C J EMPLOYEE #: 2 DATE: I Z� V t Date Service Completed (if already completed): SERVICE CODE: tG�� Plb `Z3ts� Fee Amount: �� s , Amount Paid I S 0)— Payment Date Y Payment Type Invoice # Check # Received By:" EHD 48-02-025 SR FORM (Golds 2pl — REVISED 11/17/2003 /