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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property L- FACILITY ID # poOZ� BUSINESS NAME,�J // SERVICE REQUEST # OWNER / OPERATOR Eu. we ✓ h /" eL-15 n CHECK If BILLING ADDRESSLJ FACILITY NAME HOME Or LING ADDRESS 1"9" SITEADDRESS ///jam (/treet Number Direction 3. c - 6 3� �D�`'�lni.,r�� F�5(tree`l�N ameess`TY �_ _/'• o�Cit EMPLOYEE #: �12`/� Zip Code HOME Or MAILING ADDRESS (If Different from Site Address) 1-;20. 13&x / Street Number Street Name CIN J i� e /N STATE ZIP G� PHONE #1 ( ) Exr' APN # Fee Amount: Ib "- LAND USE APPLICATION If PHONE#2 EZ . Payment Type �/ BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR L- CHECK If BILLING ADDRES BUSINESS NAME,�J // PHONE# Eu. we ✓ h /" eL-15 FEB 2 3 Zoog HOME Or LING ADDRESS 1"9" FAx# woq) 3. c - 6 3� b �� EMPLOYEE #: /3�o CITY (�'' STATE / ZIP v y;z 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 work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, Standards, STATE RAL laws. - APPLICANT'S SIGNATURE: DATE: PROPERTY/ BUSINESS OWNER ❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT IfAPPLICANT 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. TY E F JTAVWYXTED: L- P CiU100 C098[)l FEB 2 3 Zoog SAN IRON N �UMTY �� OWAL E A TMEN-r ACCEPTED BY: EMPLOYEE #: DATE: ASSIGNED TO: EMPLOYEE #: DATE: Date Service Completed (if already completed): SERVICECODE: PIE: ?/ Fee Amount: Ib "- Amount Paid 9/p Payment Date o � 3 0 Payment Type �/ Invoice # Check #376-1 ecelved By: EHD 48-02-025 SR FORM (Golden Rod) REVISED 11/17/2003