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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property C //l�C_ FACILITY ID # BUSINESS NAME C l -� ERVICE REQUEST # /?f<, PHONE# EXT. HOME or MAILING ADDRESS i> ,�, T (� x `3 -19 4u, tN ZS) OWNER / OPERATOR CITY CHECK If BILLING ADDRESS rl' /Z 9❑ A)ZUL EP LLE Fee Amount: �Q Amount Paid FACILITY NAME Payment Type v n/0R /LE 1 Received By: SITE ADDRESS/ 7 A/ �✓�� -T Street Number Direction Stre Name City Zip Code HOME or MAILING ADDRESS (If Different from / Site Address) 71 //Z D Street Num/ber Street Name CITY/ $TATE, ZIP �Pgl r� 5-9— PHONE #1 EXT. APN # LAND USE APPLICATION # (a�) 3g? -072(' os I -/ 50 — Aq 7 PHONE #2 EXT• BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR Po o C //l�C_ CHECK If BILLING ADDRESS ❑ BUSINESS NAME C l -� ate. C62�s t,r / ��► EMPLOYEE #: PHONE# EXT. HOME or MAILING ADDRESS i> ,�, T (� x `3 -19 DATE: " f FAx ) CITY _ SERVICE CODE; Z E: STATE CA ZIP 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 I COUNTY Ordinance Codes, Standards, APPLICANT'S SIGNATURE: cation and that the work to be performed will be done in accordance with all SAN JOAQUIN TE and Fx0ERAL laws. PROPERTY/ BUSINESS OWNER OPERATOI{/ MANAGER ❑ If APPLICANT is not the BILLING PARTY, proof of DATE: b 1 7� OTHER AUTHORIZED AGENT 19 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 environmentaUsite assessment information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available andme time it is provided to me or my representative. TYPE OF SERVICE REQUESTED: COMMENTS: I / Zfjry� SAIV ° N,p1N CO HgNAR U✓LN7lTHpE MENT ACCEPTED BY: EMPLOYEE #: DATE: ASSIGNED TO: EMPLOYEE #: + DATE: " f Date Service Completed (if already completed): _ SERVICE CODE; Z E: Fee Amount: �Q Amount Paid Payment Date Payment Type I Invoice # Check # 39"�6,5- 1 Received By: EHD 48-02-025 REVISED 11/17/2003 SR FORM IN