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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property CHECK If BILLING ADDRESS FACILITY ID # SERVICE REQUEST # PHONE# ExT zo Sq -02,S HOME or MAILING ADDRESS 16 Kner e s X7 '04 OWN�jt/OPERATOR STATE ! ZIPgjZ 9 (\T/ QV - O CHECK If BILLING ADDRESS FACILITY NAME MFN Ca e r lilt SITEADDRESS EMPLOYEE #: DATE: tko Li FfeH?peti s Gic'I7i.7 9 Street Number Dlreetlon Street Name City Ila Call. HOME or MAILING ADDRESS (If Different f/r�om Site Address) Amount Paid t UV Ou.X v( / Street Number Street Name CITY -0-a -o„ Received By: STATE G n ZIP PHONE 91 Exr. APN # LAND USE APPLICATION # (2oq ) 35)- ` IqZ PHONE #2) (2oq-726 Ex . BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR CHECK If BILLING ADDRESS BUSINESS NAME/i /f / m il — e t ` na'4")-eri G 1< PHONE# ExT zo Sq -02,S HOME or MAILING ADDRESS 16 Kner e FAX# ( CITY �fDCk-`,0/) STATE ! ZIPgjZ 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 laws. APPLICANT'S SIGNATURE: � C� �_ DATE: V U J O' gI Z a 2 PROPERTY/ BUSINESS OWNER❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT El D(,mer IfAPPLICANT 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 the or my representative. PA Iia TYPE OF SERVICE REQUESTED: G 1< COMMENTS: A J�jy 0 C/ 9 Vv, 7N CO IY HpE MFN lilt ACCEPTED BY: EMPLOYEE #: DATE: ASSIGNED TO: I EMPLOYEE #: DATE: Date Service Completed (if already completed): SERVICE CODE: P/ Fee Amount: D Amount Paid t UV Payment Date Payment Type Invoice # Check # Received By: EHD 48-02-025 SR FORM (Golden Rod) REVISED 11/17/2003