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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property CHECK If BILLINGADORESS FACILITY ID # yyI 1 n( I SERVICE REQUEST # PHONE # Ems• HOME Or MAILING ADDRESS 2SOt COMMENTS: <36 00 501 q OWNER / OPERATOR n Own o y b�\ AUG U 4 d) 22 ENVIRONMEOU COUNTY HEALTH ACCEPTED BY: S) CHECK if BILLING ADDRESS EMPLOYEE #: DATE: ASSIGNED TO: S` FACILITY NAME �n �10o rn �c�ItUp nd Q �P(C h ` S�TlV� to SERVICE CODE: L I . lDate SITE ADDRESS ytr Fee Amount: IE! Amount Paid l II'1 q 210;�l Payment Type •I t a C y 5' 7 5'treet Number Direction Street Name CIIl Zip Code HOME or MAILING ADDRESS (If Different from Site Address) i`T Street NumbeY Street Name CITY STATE ZIP PHONE #I En. APN # LAND USE APPLICATION # ( 26 Ll PHONE#2 En' BOS DISTRICT LOCATION CODE CONTRACTOR /SERVICE REOUESTOR REQUESTOR BILLING ACKNOWLEDGEMENT: I, the CHECK If BILLINGADORESS BUSINESS NAME y/l A J yyI 1 n( I PHONE # Ems• HOME Or MAILING ADDRESS 2SOt COMMENTS: FAx# CITY STATE ZIP undersigned property or business owner, operator or authorized agent of sante, 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. APPLICANT'S SIGNATUREKJZ DATE: d PROPERTY/ BUSINESS OWNER❑ OPERATOR / MANAGER ❑ OTHER AUTHORIZED AGENT ❑ If APPLICANT is not the BILLING PARTY proof of authorization to sign is required Tire 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 the same time It is provided to the or my representative. DAabsi__ clo TYPE OF SERVICE REQUESTED: CUI t� VL� RE G COMMENTS: AUG U 4 d) 22 ENVIRONMEOU COUNTY HEALTH ACCEPTED BY: S) EMPLOYEE #: DATE: ASSIGNED TO: S` EMPLOYEE#: DATE: Date Service Completed (if already completed): SERVICE CODE: L I . lDate PIE: 10 Fee Amount: IE! Amount Paid l / A �• Payment t.r i q 210;�l Payment Type Invoice # Received By: EHD 48-02-025 SR FORM (Golden Rod) REVISED 11/17/2003