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SAN JOAQUI, .OUNTY ENVIRONMENTAL HEALTH DErARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID# SERVICE REQUEST# �� ► �Vi6 OWNR OPERATOR G_ 1 CHECK If BILLING ADDRESS FACILITY NAME SITEADDRESS _2sq Street Number Direction Streat Name U CI Zip Code HOME Or MAILING ADDRESS (If Different from Site Address) L, L y SO r Street Number Street Name CITY STAJE ZIP c S I-C khtZVx Cf,5`� 0 5 PHONE#)1 Gr2�c'��t�,2 ei{3 9//�. EKr. APN# LAND USE APPLICATION# PHONE#2 EXT. SOS DISTRICT LOCATION CODE ( ) CONTRACTOR/ SERVICE REQUESTOR REQUESTOR - 5Tu11 ll_v e""r CZU(C) CHECK If BILLING ADDRESS BUSINESS NAME PHONE EKT. CCLV V t ddtA �90a a15r 'a s Ila. HOME Or MAILING ADDRESS FAX# .?4 4 fG ( a( Sea ( ) CITY 5 U _I I '^' STATE o/1 _ ZIP 56.2 v S 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,STATE and FEDERAL laws. ; / APPLICANT'S SIGNATURE: �a,Cy/ (�z� DATE:\' e- C2_3 _ S PROPERTY/BUSINESS OWNER[I 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 It Is provided to me or my representative. PA Va. TYPE OF SERVICE REQUESTED: U� �� T COMMENTS: SgNJAPR p 3 201 Hf LTjt0O IV CO �M ACCEPTED egt EMPLOYEE#: —5-56-6 DATE: f//9� ASSIGNED TO: Date Service Completed (if already complet d): �l SERVICE CODE: O PIE: ��oa Fee Amount: Amount Paid13a b� Payment Date �/3/S-- Payment Type-1Invoice# Check# Received By:� EHD 48-02-025 07/17/08 SR FORM(Golden Rod)