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SJOAQUIN*UNTY ENVIRONMENTAL HEALTH MARTMENT R ECEIVECN SERVICE REQUEST Type of Busines r Tperty Q DEC IM�✓ �� `l 1 �� FACILITY ID # SERVICE REQUEST # �-��vi �Ss� HOME Or MAILING ADDRE$S� 1 V /� P 1 r�^/�V l CHECK If BILLING ADDRESS FACILITY NAME EMPLOYEE#: O?)Z ENVIR PAI 1W SITE ADDRESS 32(� —2 Street Number I Direction Street Name Date Service Completed (if already completed): Cit Zip Code HOME or MAILING ADDRESS (If Different from Site Address) pa-)— Street Number I ( -;�6 111:5 I�� I" Street Name 1^ n, n CITY `I'1� `�Zll' ZIP S E 6 �lX %�'��n PH NE #1Y b l APN # Payment Type LAND USE APPLICATION # PHONE #2 EXT. ( ) Check # 02 © BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR CHECK If BILLING ADDRESS 1� be A n BUSINESS NAME 11V10- PHON� 2_ HOME Or MAILING ADDRE$S� 1 V /� P 1 r�^/�V l FAx q�0_ 2 CITY STAT J�/-' ZIP BILLING ACKNOWLEDP EMENT: 1, 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, STAT d FE RAL laws. APPLICANT'S SIGNATURE: f'j DATE; 1O PROPERTY /BUSINESS OWNER ❑ E TOR /MANAGER ❑ OTHER AUTHORIZED AGENT If APPLICANT is not tffe BILLING PARTY, proof of authorization to sign is required Tit 1 e 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: COMMENTS: 4Z//.j//fi /3/�y/.o_ D��✓�'s^ e¢ ��,��r iz-s�.�.e.��.�n l•u�'2�-F�A'�M� -�u..�:� c�cu ya�.��.-,1 �� 2 - /) REC IVED SD�C 1-51 2010 ACCEPTED BY: ©�tv�( EMPLOYEE#: O?)Z ENVIR PAI 1W IVI€NIT 2fIS C(� )EIRA21W NI DATE: /a/1V/J ASSIGNED TO: �!'S'd .� ` EMPLOYEE #: 7 8 L% Date Service Completed (if already completed): SERVICE CODE: 3� P I E: Fee Amount Amount Paid zqlPayment Date Payment Type Invoice # Check # 02 © Received By: EHD 48-02-025 SR FORM (Golden Rod) REVISED 11/17/2003