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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property `''C� COMMENTS:�� / 1 `� IiW► LGa11C Ladle �Sayl FACILITY ID # SERVICE REQUEST # ( 4 ), (_. BUSINESS NAME S4DO S OWNER / OPERATOR AZ— _ 78 2� HOME Or MAILING AD�ESS DATE: e oZ {1 2 1 ENT CHECK if BILLING ADDRESS ❑ FACILITY NAME DATE: -Y a6 d Date Service Completed (if already completed): SITE ADDRESS Qt STATEc6q ZIP C 1 I P / E: iit�t Amount Paid / • �� Number Direction # : iib 44LO (e - Street Nameit Zi Code HOME or MAILING ADDRESS (If Different from Site Address) Street Number Street Name CITY STATE ZIP PHONE #1 EXT. � APN # o$�� as �i LAND USE APPLICATION #CIL( � PHONE #2 EXT. BOS DISTRICT LOCATION COD CONTRACTOR / SERVICE REQUESTOR REQUESTOR `''C� COMMENTS:�� / 1 `� IiW► LGa11C Ladle �Sayl OFj VF CHECK if BILLING ADDRESS M Ll 5 OA BUSINESS NAME PHONE # EXT. AZ— _ 78 2� HOME Or MAILING AD�ESS DATE: e oZ {1 2 1 ENT FAX # EMPLOYEE#: DATE: -Y a6 d Date Service Completed (if already completed): CITY STATEc6q ZIP C 1 I 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 ( 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 laws. APPLICANT'S SIGNATURE: pL, � —� DATE: AICA �G = 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. TYPE OF SERVICE REQUESTED: sv;) 'ju ' 1C' W1 J hN t QUI e l Drchr J�TU)2eview `''C� COMMENTS:�� / 1 `� IiW► LGa11C Ladle �Sayl OFj VF 4007 Z 6 NV R0 V/N C0 //V F'gCTyO pMFNTNN�, AZ— ACCEPTED BY: % EMPLOYEE #: DATE: e oZ {1 2 1 ENT ASSIGNED TO: /115 EMPLOYEE#: DATE: -Y a6 d Date Service Completed (if already completed): SERVICE CODE: 3 P / E: Fee Amount: kc 9 Amount Paid / • Payment Date 8 24 Payment Type011241 � pia & Invoice # # : iib 44LO (e - Received By: EHD 48-02-025 REVISED 11/17/2003 V SR FORM (Golden Rod) T