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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property 9, 2— l,: �LCHECK If BILLING ADDREExScS FACILITY ID # SERVICE REQUEST # P 36 HOME or MAILING A D F.� _ ,✓ y� FN �Ro fv CO HFgCTy OWNER OPERATO U i 'e �2 CHECK if BILLING ADDRESS FACILm NAM SEN ACCEPTED BY: SITE ADDRESS EMPLOYEE#: /� L13 �V1j DATE: ' 2- /z-/ ASSIGNEDTO: ' ( G �j .` EMPLOYEE#: I Q : 1 Street Number Dlrectlonali/G,//LStreet ll Name SERVICE CODE: i r/�j/ 'Itif Zip Cod HOME or MAILING ADDRESS (If Different from Site Address) y H9`7,1 / , �/ Payment Date Payment Type Stre¢t NNNumber Stree am� CITY Receiv d By: STATE ZIP 4�i 75L PHONE #1 Ezr. APN # LAND USE APPLICATION # PHONE#2 ( ) Exr. BOS DISTRICT 11 LOCATION CODE' CONTRACTOR / SERVICE REQUESTOR REQUESTOR `µ //Y) 9, 2— l,: �LCHECK If BILLING ADDREExScS BUSINESS NAM i COMMENTS: P 36 HOME or MAILING A D F.� _ ,✓ y� FN �Ro fv CO HFgCTy CITY %% STATE Zip 4 vj 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, Standar , ATE and FEDE L laws. APPLICANT'S SIGNATURE: Jar/j?j � �j7 s/e•� + DATE: �IZ 277 PROPERTY / BUSINESS OWNERQ 'OPERATOR/ 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 enviro ental/site assessment information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available areA f �et �time it is provided to me or my representative. t rtl TYPE OF SERVICE REQUESTED: e� COMMENTS: 6qN J 1 L✓J2� FN �Ro fv CO HFgCTy pEPgR SEN ACCEPTED BY: _ EMPLOYEE#: /� L13 �V1j DATE: ' 2- /z-/ ASSIGNEDTO: ' ( G �j .` EMPLOYEE#: I Q : 1 DATE: J%/IZl lZz— Date Service Completed (if already completed): SERVICE CODE: i PIE: i J I Fee Amount: l I — ! \IInnvoice Amount Pai /S/ r Dn I Payment Date Payment Type # Check # Receiv d By: EHD 45-02-025 REVISED 11/17/2003 ORD) 53010 9 SR FORM (Golden Rod)