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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property ----F T •� Ha (- 'N -%-k` � - FACILITY ID # BUSINESS NAME /� JQ1 i / I ` SERVICE REQUEST # \� C- PHONE �' Ext. — 1 e - 25!3 ) L) r- si0-0ow2s(e. OWNER/OPERATOR L— n t l M Q� �' \V CHECK if BILLING ADDRESS FACILITY NAME (Cher �L ACCEPTED SITE ADDRESS 2-70 11\; EMPLOYEE III: _I J L- DATE: ASSIGNED TO: /` Street Number Direcllon Stree ama Clt Zi Cod. HOME or MAILING ADDRESS (If Different from Site Address) Fee Amount: 'd Amount Paid 'a L ' (D - Street Number Invoice # Street Name CITY Received By: ujQl:�-11— [ STAIE4 ZIP � Q /l'_ c__J PHONE #I Exr. (2rr) LA83- 32-7fi APN # LAND USE APPLICATION # PHONE#2 EXT. ( ) BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR ^ T •� Ha (- 'N -%-k` � CHECK If BILLING ADDRESS® BUSINESS NAME /� JQ1 i / I ` ' ` r �/`'o1 �\ J \� C- PHONE �' Ext. — 1 e HOME or MAILING ADDRESS 16? ib ) L) r- Frx# (2(r1) Z - DD r. CITY S+0 / 4-D ^ STATE (_q ZIP a s 7z BILLING ACKNOWLEDGEMENT: 1, 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. 1 also certify that 1 have prepared this appli I and, hat th • work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, Standards, SATE a I F L laws. APPLICANT'S SIGNATURE: - DATE: G7�>Z S PROPERTY/ IIUSINESS OWNER❑ R/ID R ❑ OTHER AUTHORIZED AGENT CeJ� C_+70r /f APPLICANT is not the BILLING PART , proof of authorization to sign is required Title AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, 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. EHD 48-02-025 REVISED 11/17/2003 '' r,, t w + 1'A t 1 SR FORM (Golden Rod) TYPE OF SERVICE REQUESTED: RECEIVED COMMENTS: COMMENTS: MAY 2 3 2011 SAN JOAQUIN COUNTY ENVIFIHEALTH DEPEARIMMENT ACCEPTED EMPLOYEE III: DATE: ASSIGNED TO: /` EMPLOYEE #: r'] / DATE: Date Service Completed (If already completed): SERVICE CODE: ZZ PIE: Fee Amount: 'd Amount Paid 'a L Payment Date Payment Type u�' Invoice # Check # 1 3 (o Received By: EHD 48-02-025 REVISED 11/17/2003 '' r,, t w + 1'A t 1 SR FORM (Golden Rod)