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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property BUSINESS NAME C Nv►12otu/I�t7.�aT14� EN�� rlvL, FACILITY ID # EyRVICE REQUEST # S�� FAX # ( ) CITY 61-11 � o STATE ZIP S�2 p ACCEPTED BY: L - Z- EMPLOYEE #: OWNER / OPERATOR ASSIGNED TO: / 1< (� ❑ EMPLOYEE #: DATE: 7 ,:2oT d.2 CHECK if BILLING ADDRESS FACILITY NAME t L- V K T 1",'6 �� 2 SERVICE CODE: <-, SITE ADDRESS ) i 10 1G 2- P 1 E: / j • ` Amount Pai L Payment Date Street Number Direction IStreet Name city Zip Code HOME or MAILING ADDRESS (If Different from Site Address) i1a..-7 R bAti7 L'/t2 �? L.— 1- Street Number [T Street Name CITY G 0 I t o STATE ZIP G Ci 57ct PHONE #1 ExT• APN # LAND USE APPLICATION # (451) 212- oCo 2 56�) - p-27 PHONE 92 ( ) EXT. BOS DISTRICT L' LOCATION CODE G - CONTRACTOR / SERVICE REQUESTOR REQUESTOR �a � � �E- /� ,r CHECK if BILLING ADDRESS ^ iz L" WE C,7 1` "7 BUSINESS NAME C Nv►12otu/I�t7.�aT14� EN�� rlvL, PHONE # EXT. 6'( 2,-L-q3o�v HOME or MAILING ADDRESS T 71 )LoQZ Kc>P.D FAX # ( ) CITY 61-11 � o STATE ZIP S�2 p BILLING ACKNOWLEDGEMENT: 1, 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 1 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 FE ERAL laws. APPLICANT'S SIGNATURE: DATE: ?%2o12Z PROPERTY / BUSINESS OWNER❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT �0 1p"'PJ I IfAPPLICANT is not the BILLING PARTY, proof of authorization to sign is required Title AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, 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 ke same time it is provided to me or my representative.. , TYPE OF SERVICE REQUESTED: COMMENTS: JUL S'gIV,/pq U`9? PgRNTAC n, TMFNT ACCEPTED BY: L - Z- EMPLOYEE #: DATE: 1'20 a.." ASSIGNED TO: / 1< (� EMPLOYEE #: DATE: 7 ,:2oT d.2 Date Service Completed (if already completed): SERVICE CODE: <-, P 1 E: / Fee Amount: 0 j. Amount Pai 3 1 Z - O� Payment Date Payment Type Invoice # Check # .2 Received By: EHD 48-02-025 SR FORM (Golden Rod) REVISED 11/17/2003