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a` ° SAN JOAQU. 7-OUNTY ENVIRONMENTAL HEAL' DEPARTMENT SERVICE REQUEST Type of Business or Property45 CHECK If BILLING ADDRESS FACILITY ID # -7 Lf -5 SERVICE REQUEST # 57ko5P?55Z� OWNER I OPERATOR PNS# 33y —2 �- ( En c CHECK If BILLING ADDRESS FACILITY NAME — HOME Or MAILING ADDRES SITE ADDRESS ae Number (Strreet ' - / DIr a ion �u Street Name CI 2i ode HOME or MAILING ADDRESS (If Different from Site Address) Street Number ACCEPTED BY: Street Name CITY EMPLOYEE#: �3 Z1 STATE ZIP PHONE#i En. ( ) U�C . S APN# 09-7-7--5--o -(y LAND USE APPLICATION# PHONE #Z Ex . Date Service Completed (if already completed): BOS DISTRICT �2— LOCAT107 CODE CONTRACTOR / SERVICE REQUESTOR R.EQUESTOR/ !' Y CHECK If BILLING ADDRESS } BUSINESS NAME 1'Ji PAYMENT PNS# 33y —2 �- ( En c RECEIVED HOME Or MAILING ADDRES ... FAX# MAR 1 1 2009 CITY / /. STATE ZIP 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 tha work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, Standards, STA ERAy awl APPLICANT'S SIGNAT DATE: // D PROPERTY / BUSINESS OWNER ❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENTP- 1,ffAPPL1CANT is not the B1LLrNGPARTY 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 environmcmal/site assessment information to the SAN JOAQUIN COUN'T'Y ENVULONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is nrnvided to me or my reDresentative. TYPE OF SERVICE REQUESTED: fZtL' �. }-I .-- COMMENTS. PAYMENT RECEIVED MAR 1 1 2009 SAN JOAQUIN COUNTY ACCEPTED BY: Dt— CL/£ I �/-F EMPLOYEE#: �3 Z1 D NT ASSIGNEDTO: U�C . S EMPLOYEEM G t Lf DATE: 31t,109 Date Service Completed (if already completed): SERVICECODE: _52,Z PIE:..3k,0.2_ Fee Amount:a(O • Tr -1 Amount Paid _ Payment Date 3 1 \ 0 Payment Type / Invoice # Check # 3 S Received By: [ylT— ENn AR.m_m5 SR FORM (Golden Rod)