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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property CHECK If BILLING ADDRESS FACILITY ID # SERVICE REQUEST # ACCEPTED BY: EMPLOYEE M 9 BUSINESS NAM DATE: a ASSIGNED TO: 4e�_ OW> / OPERATOR EMPLOYEE #: 9 CHECK If BILLING ADDRESS Date Service Completed (if already completed): HOME ADDRESS � FACILITY NAME - LO -�r-MAILING Ll KVOLOL 1v � 6 ( ( ) Date Payment Type 17 SITE ADDRESS L46 7 �; CITYC ' IDA l 5 I I ,r I� /, 1) r da aq StreetNumberDirection '/n � eX t _ 1—$ltreetl'Na ie J 1Cit a Zip Code HOME or MAILING ADDRESS I(if Different from Site Address) L �FN /1 vq �Streeet V" Z Street Number Name CITY j `'i ST,QzE ZIP PHONE #1 ExT• APN # LAND USE APPLICATION # ('7� bc rno��l PHONE# Exr. BOS DISTRICT LOCATION CODE CONTRACTOR /SERVICE REQUESTOR REQUESTO CHECK If BILLING ADDRESS COMMENTS: as ACCEPTED BY: EMPLOYEE M 9 BUSINESS NAM DATE: a ASSIGNED TO: 4e�_ PHONE # Exr. EMPLOYEE #: 9 DATE: 1 7 Date Service Completed (if already completed): HOME ADDRESS � FAX# LO -�r-MAILING Ll KVOLOL 1v � 6 ( ( ) Date Payment Type 17 Invoice # CITYC ' IDA l 5 STATE 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 application and that the work to COUNTY Ordinance Codes, Stanllkr�?s; ST�'Eand-1iEpERAL laws APPLICANT'S SIGNATURE: PROPERTY / BUSINESS OWNER If APPLICANT is not the / NL4NAGER ❑ OTHER will be done in accordance with all SAN JOAQUIN DATE: Y ) l• �L-.'l / � L _ :ENT ❑ proof of authorization to sigh 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, geotecluiical 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 me or my representative. PA Vi. M_ TYPE OF SERVICE REQUESTED: A _ \ A VA OA ON FC COMMENTS: Ll�� S I ,10 ` 202Z/v2 HEq Th QE M�qQljttENTg4 ry gRrM�Nr ACCEPTED BY: EMPLOYEE M 9 DATE: a ASSIGNED TO: 4e�_ EMPLOYEE #: 9 DATE: 1 7 Date Service Completed (if already completed): SERVICE CODE: P/10 IIO Pie: o4 Fee Amount: , 5 G Amount Paid J Payment Date Payment Type 17 Invoice # eck l 5 ( Received By: EHD 48-02-025 SR FORM (Golden Rod) REVISED 11/17/2003