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C • SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Ty a of Business or Property FACILITY ID # SERVICE REQUEST # � n � (n 3, o �lt,(� EXT. 1 - a FAx#l /�v /) r ,/ -41/� ! ^loIT- OWNER/ OPERATOR ZIPt 15;15 CHECK If BILLING ADDRESS FACILITY NAME f��r�^ �rt W" SITE ADDRE S �' I EMPLOYEE #: (t�� y(�1 ASSIGNED TO: EMPLOYEE#: Street Number Direction ` StreeTName P 1 E: Fee Amount: 7 "— Cc HOME or MAILING ADDRESS (If Different from Site Address) '5 3-7 S. 01D Payment Date � zr t' Street Number Invoice # Street Name CITY I Received By: STATE ZIP PHONE #1 EXT. APN # LAND USE APPLICATION # PHONE #2 EXT. ( 1 BOS DISTRICT�' LOCATION CODS 1 CONTRACTOR / SERVICE REQUESTOR REQUESTOR _ In -)In, CHECK if BILLING ADDRESSEY BUSINESS NAME LIAL Io�J�s PHON (w EXT. 1 - HOME or MAILING ADDRESS V�J 1 ctr f ► I FAx#l /�v /) r ,/ -41/� ! ^loIT- CITY I ' STATE ' A ZIPt 15;15 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, TE and FEDERAL laws /� / APPLICANT'S SIGNATURE: ( V -;? �,{�� fi 1� DATE: 412. — ( l PROPERTY / BUSINESS OWNER ❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT t:S t l—?�— ILI& /I If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required Title Wi 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. ..r.�T TYPE OF SERVICE REQUESTED: { RECEIVED COMMENTS: SEP 2 8 2011 SAH JOAQUIN COUNTY HEALTH DE.PARTMEXT ACCEPTED BY: EMPLOYEE #: DATE: <' ASSIGNED TO: EMPLOYEE#: DATE: Date Service Completed (if already completed): SERVICE CODE: ' P 1 E: Fee Amount: 7 "— Cc Amount Paid '5 3-7 S. 01D Payment Date � zr t' Payment Type Invoice # Check # �0 I? I' �F I Received By: EHD 48-02-025 SR FORM (Golden Rod) REVISED 11/17/2003