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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID # CHECK if BILLING ADDRESS / �T SERVICE REQUEST # a Ile Z '000ZYo �'200%�{3q5 14 .e -J HOME or MAILING ADDRESS DATE: ::—/(,7 t 2 - FAX # OWNER / OPERATOR �Il'q/. / /Q�� CHECK If BILLING ADDRESS v� STATE ZIP SERVICE CODE: 2.2 PIE: 3(,o,— 3(uCi,— FACILITY NAME I Amount Paid Z5 t�a– Payment Date SITE ADDRESSit�� S/3yr�6 Z Payment Type Invoice # Check # Received By Street Number Direction Street Name City Zip Code HOME or MAILING ADDRESS (If Different from Site Address) (7// U Ct-'Wf G Street Number Street Name CITY STATE 2g ZG % PHONE#i ExT. ApN# LAND USE APPLICATION# (w5) 74- �W 3 S- PHONE#2 ExT. ( ) BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR COMMENTS: �t� CHECK if BILLING ADDRESS / �T BUSINESS NAME) PHONE# ExT. SAN JOAQUIN oMMEWAL HEALTHRDEPARNENT ACCEPTED BY: OC l u I— t Q: 2L)5 7 z - 3 S HOME or MAILING ADDRESS DATE: ::—/(,7 t 2 - FAX # EMPLOYEEM 2— (3 (2c4) V7Z CITY STATE ZIP BILLING ACKNOWLEDGEMENT: 1, the undersigned property or business owner, operator or authorized agent of sante, 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 application and that the work to be med will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, Standards, STATE an F @ISL law APPLICANT'S SIGNATURE: - DATE: PROPERTY/ BUSINESS OWNER❑ O BATOR/M.ANAGER ❑ OTHERAUTHORizEDAGENT)d IfAPPL/CA.NT is not IIIBILUNG 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 environmentaVsite 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: COMMENTS: �t� RECEIVED -Ali I'�a .,,...,,/ ` O"�" FEB 1 12012 COUNTY SAN JOAQUIN oMMEWAL HEALTHRDEPARNENT ACCEPTED BY: OC l u I— t Q: EMPLOYEE #: 32 f DATE: ::—/(,7 t 2 - ASSIGNED ASSIGNED TO: 4) it 1—+ EMPLOYEEM 2— (3 DATE: --7-// -7 f Z Date Service Completed (if already completed): SERVICE CODE: 2.2 PIE: 3(,o,— 3(uCi,— Fee Fee Amount: I rb I Amount Paid Z5 t�a– Payment Date Payment Type Invoice # Check # Received By EHD 48-02-025 REVISED 11/17/2003 SR FORM (Golden Rod)