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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID # ERVICE REQQU]EST # �- 1� CALL (209) 95 ib t'("FOR INSPECTI 48 HOUR N01 REQUIRED. ACCEPTED BY: �T� ,., �ON � v ti' R m w�-"' i v IP b e- ( ) CITY I hOrA, r -O STATE Z` ee f OWNER/ OPERATOR CHECK if BILLING ^'` ODE:! % SERVICE CODE:-D(, ADDRESS FACILITY NAME Fee Amount: 41 S Amount P SITE ADDRESS 26;`! Paymenit�Date i ri TO �Ti� Invoice # �10fNi Iry Check # r o Street Number Direction Street Name City ZI HOME or MAILING ADDRESS (If Different from Site Address) - Street Number Street Name CITY STATE ZIP 0/4 y PHONE #1 EXT. APN # LAND USE APPLICATION # 7 Sq/y ( )n) 3Ce-3c00 roo 1 "UZ0 - I JO FNV/R�UINC PHONE #2 EXT. ( ) BOS DISTRICT j LI N LOCATIO '4R7 - CONTRACTOR / SERVICE REQUESTOR REQUESTOR �> — -- CHECK If BILLING ADDRESS J I BUSINESS NAME PHONE# EXT. CALL (209) 95 ib t'("FOR INSPECTI 48 HOUR N01 REQUIRED. ACCEPTED BY: �T� HOME or MAILING ADDRESS FAX# v ti' R m w�-"' i v IP b e- ( ) CITY I hOrA, r -O STATE Z` ee eA1T lle® V1 utoy 4k ENr 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, STATE and�FEDERAL la APPLICANT'S SIGNATURE: /%,/.� DATE: Z�- -2,1 PROPERTY/ BUSINESS OWNER OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT ❑ If APPLICANT 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. TYPEOFSERVICEREQ UESTE D:Cpr- I JDe(- }IJn bF Ie4C 1I PS ,�e� s�-.rbeiGK<�J 5 FivL COMMENTS;'/ 1t1Ft;LSulQ �15}�tlNll. 0�" C�;�(ufa}e vJ�1¢yP S>tlUiF✓IP (r'iti yYteel n15-DyE4e - by awns' y F'na of 1f" th CALL (209) 95 ib t'("FOR INSPECTI 48 HOUR N01 REQUIRED. ACCEPTED BY: �T� EMPLOYEE #: DATE: ,r J ASSIGNED TO: v EMPLOYEE M DATE: S112 0' Date Service Completed (if already completed): ODE:! % SERVICE CODE:-D(, P / E: L) ,] J Fee Amount: 41 S Amount P 15�� Paymenit�Date i Payment Type Invoice # Check # Received By: EHD 48-02-025 SR FORM (Golden Rod) REVISED 11/17/2003 �e. 3-7697 ON. 'ICE