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SAN JOAQUISOUNTY ENVIRONMENTAL HEALTAOPARTMENT SERVICE REQUEST Type of Busines or Property FACILITY ID # SERVICE REQUEST # rl_O 5 '-' f Jnr f 'S IZ00 & q ©q q BUSINESS NAME ACCEPTED BY: o L- T D OWAR 1PERATO /� �i CHECK if BILLING ADDRESS I�.1 5 r a,(' lit"il r, a ASSIGNEDTO: FACILITY NAME LAC� M HOME or MAILING A RIESS o DATE: 124 [1'( R SITfADESS -7 1 �'Or � CITY Street Number Direction Payment Date Street arae O Zio Code HOME or MAILING ADDRESS (If Different from Site Address) y� � 1�'�i'��3 L� �j�j1�b� C-) � V Street Number �n- Streetllla e CITY STATE ZI�7 / `? /7(�, e T r< t PHONE #'I E.T. 93/��/S APN # LAND USE APPLICATION # PHONE029 EXT. UOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR jp D COMMENTS: CHECK If BILLING ADDRESS BUSINESS NAME ACCEPTED BY: o L- T D PHONE# EXT. EMPLOYEE M O 3 DATE: 12-/(? (f ASSIGNEDTO: C- --(-C HOME or MAILING A RIESS EMPLOYEE '4C,1��] DATE: 124 [1'( R FAX# SERVICE CODE: P I E:: 3 0� CITY t' Q STATE ZIP s- 1,2— BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of sante, acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DE>}AP'rM :NT 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 SIGNATURE: DATE: PROPERTY/BUSINESS OWNER 11 OPERATOR/ MANAGER ® OTIIERAUTIIORIZEI)AGENT T.�t IfAPPLICANT is not the FILLING PARTY, proof of authorization to sign is required Title AUTHORIZATION TO RELEASE INIaORMATION: 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 me or my representative. TYPE OF SERVICE REQUESTED: o2 -F-! 7LO 'F (-F- COMMENTS: DEC 19 2011 BAN JOAQUIN C.oUKN EKVIRONMZNTAL HEALTH DEPAR rKW ACCEPTED BY: o L- T D EMPLOYEE M O 3 DATE: 12-/(? (f ASSIGNEDTO: C- --(-C EMPLOYEE '4C,1��] DATE: 124 [1'( R Date Service Completed (if already completed): SERVICE CODE: P I E:: 3 0� Fee Amount:) -7 Amount Paid '�j'l 0 0 Payment Date >< Payment Type �St# Invoice 1�'�i'��3 L� �j�j1�b� Received By: EHD 48-02-025 SR FORM (Golden Rod) REVISED 1111712003