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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property �P �t L ()?PS Y12eYj 5(2"4,5?, l , FACILITY ID # BUSINESS NAME SERVICE REQUEST # Q rL /\,) ) \ EXT. "? HOME or MAILING ADDRESS, �� OWNER / OPERATOR CITY O STATE 0 0 �,�, Q w C a �� rJ CHECK If BILLING ADDRESS FACILITY NAME DATE: Q JI 7 Date Service Completed (if already completed): SITE ADDRESS SERVICE CODE: r I A /1 /� /� w -N� +(.Street Fee Amount: "� S.L,�i i/ 7 tN!`-CI-t l q Street Number Direction Payment Type �( Name 2 (31 5�i f2 Zi Code HOME or MAILING ADDRESS (If Different from Site Address) Street Number Street Name CITY STATE ZIP PHONE #'1 EXT. APN #/ LAND USE APPLICATION # ( ) Cob 11 d - PHONE #2 EXT• ( 1/.3 8-- 6 G BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR // - /L ` 0 l J full �P �t L ()?PS Y12eYj 5(2"4,5?, l , CHECK If BILLING ADDRESS BUSINESS NAME (HONE #) Lo) ) \ EXT. "? HOME or MAILING ADDRESS, FAx # ACCEPTED BY: �� L l� CITY O STATE ZIP 0 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. e� APPLICANT'S SIGNATURE:�f�{�c�' l DATE: PROPERTY/ BUSINESS OWNER 13 OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT If APPL/CANT 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 e It is provided to me or my representative. 7. TYPE OF SERVICE REQUESTED: i<V(? t 1 %� It, � l ;,r 4 r �P �t L ()?PS Y12eYj 5(2"4,5?, l , COMMENTS: 0, � FN °qQ��N 202 HFA H 174M ANT ACCEPTED BY: �� L l� EMPLOYEE #: DATE: C11-1/07/ J ASSIGNED TO: /� l �, EMPLOYEE #: DATE: Q JI 7 Date Service Completed (if already completed): SERVICE CODE: r I P I E: 9 a IDa Fee Amount: "� Amount Paid 1�J� Payment Date 2 j Payment Type �( Invoice # 2 (31 5�i f2 Received By: ' EHD 48-02-025 SR FORM (Golden Rod) REVISED 11/17/2003