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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH IEPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID # CHECK if BILLING ADDRESS SERVICE R�EQUUEEST # NEC IW f. 83, -4Lo�% HOME or MAILING AJDD/RtEiSS,a 3 t-c�Y '�P2. OWNER / OPERATOR d.A Fp%# (Wei) 93 3 '9 22.E ?Af elt 4 f5^ A /' /��f. -r fJ./"- 1— La r r( rry5--�r7 C� fro CHECK if BILLING ADDRESS FACILITY NAME r—Y Atppeo #:ifl3 Zr SIITEADgqDRESS ASSIGNED TO: f--Y)4A7-A- EMPLOYEE#: (0 2-4 DATE: Date Service Completed (If already completed): Street NumberDirect! o '" Street Name Fee Amount: Z L ro Cit 'Zi�Gotle HOME or MAILING ADDRESS (If Different from Site Address) Pa menti a Y yp Invoice # Street Number Received By: Street Name CITY STATE zip PHONE11 E"T ( ) �3S- 465 APN # LAND USE APPLICATION # PHONE #2 EXT. ( I BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REOUESTOR REQUESTOR x ✓LEP+4't.Q �.�c L.+ -J CFFLc1�MENT CHECK if BILLING ADDRESS BUSINESS NAME SPANe I�C exfj l f4s7 �'r�` NEC IW f. 83, -4Lo�% HOME or MAILING AJDD/RtEiSS,a 3 t-c�Y '�P2. (9n9JT Z Fp%# (Wei) 93 3 '9 22.E CIN STATE C4- zip Q f ( d 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 1 have prepared this applic 4 n and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, Standards, ST 7d FEDERAL la APPLICANT'S SIGNATURE: o DATEpp: G Z-1 PROPERTY/ BusiNESs OWNER❑ OP€RATOR/NIANAGER ❑ OTHER AUTHORIZED AGENTOK CO/1I [ rlr..7t-z2-- 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 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: (DOL 56,4 ✓LEP+4't.Q �.�c L.+ -J CFFLc1�MENT COMMENTS: NEC JUN 2 9 2011 SAN JoAOUIN COU ENVIRONMENT ,4EA TH DEPARTM ACCEPTED BY: Lfoe4 IleEMPLOYEE #:ifl3 Zr DATE: b ^D y ASSIGNED TO: f--Y)4A7-A- EMPLOYEE#: (0 2-4 DATE: Date Service Completed (If already completed): SERVICECODE: '("Z� P 1 E: Fee Amount: Z L ro Amount Paid �a t� Payment Date 6 / ��/�i Pa menti a Y yp Invoice # r Check # J I Z(o Received By: EHD 48-02-025 REVISED 11/17/2003 SR FORM (Golden Rod)