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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID # n J SERVICE REQUEST # BUSINESS NAME O �OO d L7�a PHON EXT. � OWNER I OPERATOR T L'LEN � C CHECK If BILLING ADDRESS FACILITY NAME 7-"� Gv`f. SAN JOAQUIN COUNTY } to CITY erc--s 0. STATE ZIP I'i-307 SREADDRESS %J-�.�..c✓/�)/ �J I `L < DATE: 4� Street Number Direction Q t e. Nan e.51 I Zia Code HOME orMAILING RES$ (If Different from Site Address) Fee Amount: Amount Paid '^ 6L /1 Street Number Y ' `� (fit Street Name CITY -5 �/ ATE IP oG t^ti 1 I\4 C'� ns O N PHONE #1 EXT. APN if LAND USE APPLICATION # ( WI�u4-�r a PHONE #2 E.T. ( oR1 64�( yg6o BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUE$10 J CHECK if BILLING ADDRESSp BUSINESS NAME O RECEIVED PHON EXT. HOME or MAILINNGADDRE$s JUN 0 2 2009 FAX# 7-"� Gv`f. SAN JOAQUIN COUNTY ( I CITY erc--s 0. STATE ZIP I'i-307 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, STA pnd�ERY la s. APPLICANT'S SIGNATURE: /Y DATE: PROPERTY/ BUSINESS OWNER 11 OPERATOR/MANAGER❑ OTHERAUTtrom NT❑ YAPPL;ICAM' is not the BILLING PAR Tr proof of authorization to sign is required Title AUTHORIZATION TO RELEASE 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 sante time it is provided to me or my representative. TYPE OF SERVICE REQUESTED: L PAYMENT COMMENTS: RECEIVED JUN 0 2 2009 SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT ACCEPTED BY: EMPLOYEE #: DATE: ASSIGNED TO: EMPLOYEE#: L� DATE: Date Service Completed (if already completed): SERVICE CODE: v L P 1 E: d Z Fee Amount: Amount Paid 1 —0 1 Payment Date 'P Payment Type Invoice # Check # /02-17 Received By: EHD SR FORM Golden Rod REVISEDSED 1111 11/17/2003 ( I