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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH �_PARTMENT SERVICE REQUEST Type of Business orPr perty CHECK if BILLING AGGRESS FACILITY ID # BUSINESS AME SERVICE REQUEST # PHONE# Exr. VY DD -f Q/I� P Qc'= 9;'�/ 0,Iu/4 HOME or MAILING ADDRESS FAX # c �ih �s�'i 2�Ys �r'�C CITY STATE ZIP 99 �v ri OWNER / OPERATOR CHECK If BILLING ADDRESS FACILITY NAM ��07 �! / v SITE ADDRESS0 N S �� Stre� O / EMPLOYEE#: umber Direction f Name CI 21 Cotla Address) HOME Or MAILING ADDRESS (if DIffren from SiteS EMPLOYEE#: / DATE: �Q //T ; "` Street Number eted (if already co feted): Street Name SERVICE CODE: CITY J _TATE Fee Amount: ip 74 0 II 27 Igs e&— PHONE #1 ( ) E". APN # LAND USE APPLICATION # Receiv d By: PHONE #2 ( ) EaT. BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUE R CHECK if BILLING AGGRESS BUSINESS AME wrl PHONE# Exr. VY DD -f Q/I� P Qc'= 9;'�/ 0,Iu/4 HOME or MAILING ADDRESS FAX # �ih �s�'i 2�Ys �r'�C CITY STATE ZIP 99 �v ri 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 2"n " nt the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, Standards, STATE a EDERAL aws. APPLICANT'S SIGNATURE: DATE: PROPERTY/BUSINESS OWNER El OPERATOR/ NAGER ❑ OTHER AUTHORIZED AGENT G( '' If APPLICANT is not the BIL' ARTY, proof o orization to sign is required / 7frle �V AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property locate he above � site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assess e f tiqp/p t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It Is available and at the same time It I$�pyded to me�df19 my representative. ENV QUIN TY TYPE OF SERVICE REQUESTED: wrl COMMENTS: Cr�LLS VY DD -f Q/I� P Qc'= 9;'�/ 0,Iu/4 �ih �s�'i 2�Ys �r'�C pQ ACCEPTED BY: EMPLOYEE#: DATE ASSIGNED TO: EMPLOYEE#: / DATE: 2—h,7/17 Date Service Com eted (if already co feted): SERVICE CODE: P/E: (P Q Fee Amount: , illi Amount Pal Payment Date 2 27 Payment Type e&— Invoice # Check # 1s-9 Receiv d By: EHD 48-02-025 I SR FORM (Golden Rod) 07/17/08 i. T