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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID # CHECK If BILLING ADDRESS SERVICE REQUEST # [CvhraS I Cv M O S ' fl t7 ((JJ C PHONE# EXT. z&Y67fr—i TS q OW ERI OPERATOR FAX# a (; L� C CHECK If BILLING ADDRESS FACILITY NAME CITYC/I't/,LtJo/( i it pq M STATE CC/r - ZIP f5-3 6 / SITE ADDRESS ACCEPTED BY: EMPLOYEE#: 6 DATE: 9 3 1 Street Number Direction 'y �n i C 4,reet Name CftV Zip Code HOME or MAILING ADDRESS (If Different from Site Address) Street Number Street Name t� CITY `C Rte Da� I l J STP�TkE/Ir ZIP �j 7 /�l 6 / PHONEA E?'T coo) 69-/75 � Payment Date APN # 03 LAND USE APPLICATION # Invoice # Check # Z72 22l Ito PHONE#26 J Ex & zo 9 —/ T /V BCS DISTRICT ryV� () i LOCATION CODE a CONTRACTOR /SERVICE REQUESTOR REQUESTCR BILLING rJ e u ,p a CHECK If BILLING ADDRESS BUSINESS NAME/ /i lkc t I Cv M O S ' fl t7 ((JJ C PHONE# EXT. z&Y67fr—i TS HOMAILING ME Or ADDRESS �z FAX# a S weer NFq v Ro U/N co TH'� ( > CITYC/I't/,LtJo/( i it pq M STATE CC/r - ZIP f5-3 6 / 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 Ordinmtce Codes, Slmtdards, TATE and FEDERAL IaWS. APPLICANT'S SIGNATURE: DATE: Z Z PROPERTY/ BUSINESS OWNER❑ OPERA /MANAGER OTHERAUTHORIZEDAGENT❑ IfAPPLICANT 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 environmentallsite 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, Pd V& TYPE OF SERVICE REQUESTED: t L `C COMMENTS: Vee A . F SAP?8 SqN NFq v Ro U/N co TH'� N1 HION`.il.N i it pq M ACCEPTED BY: EMPLOYEE#: 6 DATE: 9 3 1 ASSIGNEDTO: EMPLOYEE#: 9,634 DATE: n I073/6q I INOIA Date Service Completed (if already completed): I SERVICE CODE: U P / E: 0 Fee Amount: 11 Amount Paid / aT Payment Date 21 = Payment Type C7li Invoice # Check # Z72 ecei ed By: EHD 48-02-025 SR FORM (Golden Rod) REVISED 11/17/2003 FQ D?J Ty °NT