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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business o�r�Property BUSINESS NAME I 1 1��-- lid t 1 iZ� 25 `^' 1 �v �'�el►�� FACILITY ID # HOME or MAILING ADDRESS_ I �e�e7 Ck) 1 �ooT- '( SERVICE RREQUEST # OWNER / OPERATOR CHECK if BILLING ADDRESS❑ FACILITY NAME ASSIGNED TO: 1�1 lam! EMPLOYEE #: SITE ADDRESS _Zo Cc> Street Number I Direction SERVICE CODE: rn LLA G,' l.L Street Name Fee Amount: SZ, J city Zip Code HOME or MAILING ADDRESS (If Different from Site Address) O Street Number Invoice # r , (t 1 �_ L �1J1 Stre`et_N`aame- CITY STTWe /t/lC_-t` �j \ l, STATE (P ZIP PHONE #1 Er, APN % LAND USE APPLICATION # PHONE #2 EXT. ( ) BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR CHECK If BILLING ADDRESS®, BUSINESS NAME I 1 1��-- lid t 1 iZ� 25 `^' 1 �v �'�el►�� PHONE Exr. (ZcJL, HOME or MAILING ADDRESS_ I �e�e7 Ck) 1 �ooT- '( FAX # ( ) CITY �� / //�1 1 STATE '/ ZIP �5 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. Q r APPLICANT'S SIGNATURE: �,,, _ (,1Ol: DATE: PROPERTY / BUSINESS OWNERM- OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT ❑ If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required Tette AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the prope located at the v above site address, hereby authorize the release of any and all results, geotechnical data and/or enironment ment information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and atft, rs provided to me or my representative. VFA 0._ TYPE OF SERVICE REQUESTED: f Sfv\-� �J .;y `�t /�1 t;+ NIV COMMENTS: JOAQU/ ACCEPTED BY: EMPLOYEE #: / v' DATE: ASSIGNED TO: 1�1 lam! EMPLOYEE #: DATE: Date Service Completed (if already completed): SERVICE CODE: rn P 1 E: Fee Amount: SZ, Amount Paid (� — Payment Date 1 Z Payment Type ; Invoice # # ; l 03 5 C)rZ�2ij Received By: EHD 48-02-025 SR FORM (Golden Rod) REVISED 11/17/2003