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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID # SERVICE REQUEST # L -t; � F c t ;-� 7q 4 l —9 rL Exr. OWNER/ OPERATOR rI (I EMPLOYEE #: i',) 7 1 CHECK If BILLING ADDRESS V STATECwt ' A ZIP 9S ZOJL Fee Amount: S.�iti FACILITY NAME Payment Date J 1 t �; Payment Type Q_,eE4 t7— SITE ADDRESS _Check-# I Received By: &-b Street Number Direction f✓ Street Name city Zio Code HOME Or MAILING ADDRESS (If Different from Site Address) � A � ` � V lYc Gl l��\Y Street Number Street Name CITY �}�c<ov" STATE r Wr�—Zo� ZIP PHONE #1 EXT. (2-6115) g ^4YIZ APN # 1 [03-37C- 2s LAND USE APPLICATION # PHONE #2 EXT. BOS DISTRICT LOCATION CODE (1-y!) (i 773 CONTRACTOR / SERVICE REQUESTOR REQUESTOR j-�C � lu G CHECK If BILLING ADDRESS BUSINESS NAME W, ACCEPTED BY: UC_f �, E ('- � —9 rL Exr. HOME or MAILING ADDRESS EMPLOYEE #: i',) 7 FAx # Date Service Completed (if already completed): CITY Sl -YJ K ( � � ► STATECwt ' A ZIP 9S ZOJL 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 rk to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, Standards, STATE and FE. APPLICANT'S SIGNATURE: DATE: && I 01 PROPERTY/ BUSINESS OWNER �� OPERATOR/ MANAGER Er 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 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. TYPE OF SERVICE REQUESTED: S 7 C7 t`t COMMENTS: �` ( r `' - 4 c 1�4 Cc i �c� �`i~, �cr� �� uto✓f W + �L. j/y%(� -[ ! - L L�CKJ 1�3 = -7ok1360 -1- S- CIAlint- - C12W' Ij �\5 353 ACCEPTED BY: UC_f �, E EMPLOYEE#: LCA DATE: ASSIGNED TO: U ON EMPLOYEE #: i',) 7 DATE: Date Service Completed (if already completed): SERVICE CODE: �C�Q' P 1 E: 2 303 Fee Amount: S.�iti Amount Paid Payment Date J 1 t �; Payment Type Q_,eE4 t7— Invoice # _Check-# I Received By: &-b EHD 48-02-025 o-43� SR FORM old REVISED REVISED 11!17/2003 (f/