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SAN JOAQUIN . OUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID# SERVICE REQUEST w1b —J OWNER I OPERATOR F, J z-6 T 5/ " ,J CHECK if BILLING ADDRESSM)Q � FACILITY NAME T U I G y< C (✓ C Q2 t q M SITE ADDRESS � 3��L. •'� C �Ri�"n!•T�R 1'4D S-izC�,n>^ Cj S�ll � Street Number Direction Streat Name city zip coag HOME Or MAILING ADDRESS (If Different from Site Address) Street Number Street Name CITY M IF) N'T f (4 STATE C ZIP 3—i PHONE#1 Exi. APN# LAND USE APPLICATION# T PHONE#2 EXT. BOS DISTRICT LOCATION CODE t ) CONTRACTOR! SERVICE REQUESTOR REQU ESTOR CHECK If BILLING ADDRESS BUSINESS NAME PHONE# Eu. HOME or MAILING ADDRESS FAx# CITY STATE ZIP 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. 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, STATE and FEDERAL laws. �J APPLICANT'S SIGNATURE: \ ae L yL DATE: PROPERTY I BUSINESS OWNER Z1 OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ If APPLICANT 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 t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It Is available and at the same time If Is d to me Or my representative. M TYPE OF SERVICE REQUESTED: EC COMMENTS: ( CQ- �( /—.� 11 utm SA EN�IRaMEN0AIILEN7 HEALSH OLPAP ACCEPTED BY: .�� EMPLOYEE#: DATE: gAsSIGNEDO: EMPLOYEE#: DATE:ce Completed falreadycompleted): SERVICECODE: PIE:nt: b a' Amount Paid '?D Payment Date10 Payment Type CAS Invoice# Check# Received By: EHD 48-02-028 07/17/08 SR FORM(Golden Rod)