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I tt OrN Ot SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTN " IRRMIT SERVICE REQUEST 1VAT"1r"—r I" Type of Business or Property i S S', FACILITY ID # DATE: ASSIGNED TO: W 0 n � EMPLOYEE #: DATE: � V-- I 6 'E OWNER / OPERATOR ✓) n '/ -Z Jr CHECK If BILLING ADDRESS i PIE: CA r 15:' l V Fee Amount: FACILITY NAME Amount Paid 4-052- OC) SITE ADDRESS Payment Type Invoice # Street Number Direction Street Name Ci Zip Code HOME0 MAILING ADDRESS (If Different from Site Address) CU Street Number Street Name CITY /' l P „Yl /� n/I 4 5 (#1� STATE ZIP 7 A 7 / c 5 PHONE EXT. ) APN # � v a3�s �y LAND USE APPLICATION # (-Z0 32�- u� PHONE 92 ( )VYv\ EXT. BOS DISTRICT _ � LOCATION ODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR I CHECK If BILLING ADDRES co C t '' Z BUSINESS NAME PHONE # ExT. 2-6)9 3,2- -7 L/7 7/ yE or MAILINp ADD ESS FAX # �7Li� ( ) M-14 C' _ STATE ZIP Ct�oCL ING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of s' e, ow edge that all site Qnd/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project c ty will be billed tome or my business as identified on this form. I al certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN JOA COUNTY Ordinance Codes, Standards, STATE nd FEDERAL laws. u APPLICANT'S SIGNATURE: r DATE: t PROPERTY I BUSINESS OWNER OP 7vc R / 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 t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It Is available and at the Same time It Is provided tone or my representative. TYPE OF SERVICE REQUESTED COMMENTS: Conrec SCP �' c IfCnn10C44tri fro ✓yi rx Sen I ; c, .+ ci r -i X 4UIPZG )%r1' 01ON a��a sp � ACCEPTED BY: i S S', EMPLOYEE #: DATE: ASSIGNED TO: W 0 n � EMPLOYEE #: DATE: Date Service Completed (if already completed): SERVICE CODE: ) PIE: L,I 2 (� Z Fee Amount: I S Z Amount Paid 4-052- OC) Payment Date Payment Type Invoice # Check # c8pXpc12$v Received By: EHD 48-02-025�� PERMIT I� SR FORM (Golden Rod) 07/17/08 mil FYPI ED