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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID #SERVICE BUSINESS NAMEPHONE# REQUEST#.. Ex, 0-72- E7w- 00(002 v( OWNER / OPERATOR` HOME AILI ADDRESS CHECK If BILLING ADDRESS FACILITY NAME 114 &�o t hl e or 6✓ CITY ^„ , STATEG/e SITE ADDRESS I SAN JOAQUIN COUNTY Street Number Direction ENVIRONMENTAL DEPARTMENT ACCEPTED BY: HOME Or MAILING ADDRESS (If Different from Site ddress) - DATE: Street Number Street Name ' CITY EMPLOYEE #: STATE ZIP -' PHONE #1 Em Date Service Completed APN # LAND USE APPLICATION If PHONE#2 EXT- ( ) PIE: BOS DI TR T LOCATION CODE 2 - CONTRACTOR / SERVICE REQUESTOR REQUESTOR - �LwL CHECK if BILLING ADDRESS BUSINESS NAMEPHONE# Ex, o o/ - y HOME AILI ADDRESS FAX# ' RECEIVED f ) 6 CITY ^„ , STATEG/e ZIP i BILLING ACKNOWLED&EMENT: 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, ST aad 3'� ERAL la S. �' APPLICANT'S SIGNATURE: �_ 4 DATE: PROPERTY/ BUSINESS OWNER❑ PERATOR/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 t0 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. -?00(-/-C,0,1 TYPE OF SERVICE REQUESTED: P) "}' A-ZQ2.0 COMMENTS: PAYMENT RECEIVED JUN 17 2010 SAN JOAQUIN COUNTY ENVIRONMENTAL DEPARTMENT ACCEPTED BY: EMPLOYEE M DATE: ASSIGNED TO: EMPLOYEE #: DATE! / ^7 [ Date Service Completed if already completed): SERVICE CODE: -'5-'2- 2- PIE: Fee Amount: o. pp I Amount Paid 3 b _ Payment Date (o 1 P 110 Payment Type L.—� Invoice # Check # PtAS elved By: EHD 48-02-025 UV NV I MAU SR FORM (Golden Rod) REVISED 11/17/2003