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SAN JOAQU" COUNTY ENVIRONMENTAL HEAL-- DEPARTMENT SERVICE REQUEST In Type of Business or Property ^ /Y AC QC,i�E I �¢j. FACILITY ID # -7 '3 SERVICE REQUEST # s7k09 ASSIGN D TO: BUSINESS NAMEp � 4S Date Service Completed (if already completed): 722 OWNER / OPERATOR �1 Fee Amount: Z/ O LN 5 _ HOME or MAILING ADDRES CHECK If BILLING ADDRESS FACILDY NAME FAX# Check # 3 ';�- `{ S SITE ADDRESS CITY p _/, Street Number Direction Street Name cl ZI Cotle HOME or MAILING ADDRESS (If Different from Site Address) Street Number Street Name CITY STATE ZIP PHONE#1 ExT' APN# LAND USE APPLICATION# PHONE#2 E"T' BOS DISTRICT LOCATIOry CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR /7 ^ /Y AC QC,i�E I �¢j. CHECK if BILLING ADDRESS '3 Dgne}tL o r[ NT ASSIGN D TO: BUSINESS NAMEp DATE: 3 It/ CEJ Date Service Completed (if already completed): PHONE# ExT. �3y --2 �1 Fee Amount: Z/ O LN 5 _ HOME or MAILING ADDRES 3 1 k/ 0 Payment Type �/ FAX# Check # 3 ';�- `{ S I Received By: �- CITY p _/, 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 I also certify that I have prepared this application and thayt work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, Standards, STA ERAL laws APPLICANT'S SIGNATURV.' DATE:X'/J PROPERTY/ BUSINESS OWNER 13 OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENTP- /f.4PPL/CANT is n a t the BILLING PARTY proof of authorization t0 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 time it is provided to me or my representative. TYPE OF SERVICE REQUESTED: 4 L-774 COMMENTS: F- : t -w/ C t-( E. e9�/�-� U t L - PAYMENT RECEIVED MAR 11 2009 SAN JOAQUIN COUNTY AC QC,i�E I �¢j. EMPLOYEEM 03, Dgne}tL o r[ NT ASSIGN D TO: EMPLOYEE #: G l( DATE: 3 It/ CEJ Date Service Completed (if already completed): SERVICECODE: ..5-�2 Z PI E: 3 .Z Fee Amount: Z/ O LN Amount Paid _ Payment Date 3 1 k/ 0 Payment Type �/ Invoice # Check # 3 ';�- `{ S I Received By: �- EHD 48-02-025 SR FORM (Golden Rod) REVISED 11/17/2003