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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST P (L Q 5' l e 0 y Type of Business or Property BUSINESS NAME C, Gb FACILITY ID # SERVICE REQUEST # ) HOME or MAILING ADDRESS / - /'� L 2(.p 2 u I' al�jl (1 fA 0ozip s S2 tooVL403 OWNER / OPERATOR EMPLOYEE #: DATE: G'^ `(/1 11 /i _(� . �� �w y V CHECK If BILLING ADDRESS FACILITY NAME p p f, Payment Date -7A/ SITEADDRESS Invoice # p Check # 133g17gDs Received By: Street Number Direction (� Sheet Name city Zip Code HOME or MAILING ADDRESS (If Different from Site Address) e Z Q S / �r S'}�'Y ( A // 1/ f/✓ Street Number r' ` (/� m - ` / '� Street Name - CITY CITY O a f STATEzip PHONEA EM. APN# LAND USE APPLICATION# 3s PHONE #2 Em BOS DISTRICT LOCATION CODE (log) 6 H9-333 CONTRACTOR / SERVICE REQUESTOR CHECK If BILLING ADDRESS REQUESTOR e-7i1.n / �t BUSINESS NAME C, Gb PHONE# En. U 1212G O e ) HOME or MAILING ADDRESS / - /'� L 2(.p 2 u I' al�jl (1 FAx # ( I CITY S /iTd�i STATE ZIP S� D 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 wXbe done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, Standards, STATE and FEDERAL laws A P[TCANT'S STGNATURE:o"(4 PROPERTY / BUSINESS OWNER ❑ OPERATOR / MANAGER ❑ OTHER AUTHORIZED AGENT ❑ IfAmicA11T is riot 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: C6Ww 1 yl— COMMENTS: Cvlay& 0� A-0�14\A , RECEIVED 17 2011 N OAQUICDU 1y ACCEPTED BY: 1 ��n.✓1 J C/r t EMPLOYEE #: DAT :RI fI n �K !/ ASSIGNED TO: nn EMPLOYEE #: DATE: Date Service Completed (if already completed): SERVICE CODE:py PIE: kp o' - Fee Amount `�2 _ Amount Pai ' <J �� Payment Date -7A/ Payment Type Invoice # Check # 133g17gDs Received By: EHD 48-02-025 SR FORM (Golden Rod) REVISED 11/17/2003