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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property Di V - FACILITY ID # S SERVICE REQUEST =ta ,vu BUSHESNgME SSS Do 7 8 5 i W. R1 ASSIGNED TO: "12 i- 7� 0ER/OPERATOR13 Date Service Completed (it already Completed): FAX# SERVICECODE: j( X PIE: 23 I Fee Amount: GJ' � Amount Paid CHECK If BILLING ADDRESS FACILITY NAME ' I(DW) Invoice # CITY -,_ STATE CIA ZIP 9331 4 SITE A DRESS Ta r-aGLLYO 4U'L.IZu. I TY -C. q SI.e Number 01ection Street Name city ZID Co e -iUL HOME or MAILING ADDRESS (if Different from Site Address) Slreel Number Stroet Neme CITY STATE ZIP PHONE #1 Ext. APN # LAND USE APPLICATION # p MY D - U t I ;�- ,;X ( PHONE#2 En. BOS DISTRICT LOCATIONCOOE ( 1 ©� CONTRACTOR / SERVICE REQUESTOR REQUESTOR Di V - CHECKIf BILLVIG ADDREss S BUSHESNgME PHONE# W. R1 ASSIGNED TO: "12 i- 7� HOME or MAILING ADDRESS Date Service Completed (it already Completed): FAX# SERVICECODE: j( X PIE: 23 I Fee Amount: GJ' � Amount Paid `d-[ 915 Payment Date ' I(DW) Invoice # CITY -,_ STATE CIA ZIP 9331 4 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 be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, Standards, STATE and FEDERAL laws. APPLICANT'S SIGNATURE: 4" -Y f ah J' DATE: Io PROPERTY/ BUSINESS OWNERD OPERATOR/ MANAGER D OTHER AHPHORizEOAGENT L7 C - C iro I� IfAPPLICdNT is not the BILLING PARTY proof of authon•izatiou to sign is required Ttiie 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 JO LINTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is provided to me or e- -- -- -- TYPE OF SERVICE RE .{- .� - Di V - - _ 5 -6 - COMMENTS: C19 DE UNTV � JOA ON ENj ENS H�`tN O�Pp,RTM ACCEPTED BY: iii/ (,, EMPLOYEE 111: pDIb DATE: - L ('�I ASSIGNED TO: "12 EMPLOYEEM L OI DATE: 1Q-/ 15DOVI Date Service Completed (it already Completed): SERVICECODE: j( X PIE: 23 I Fee Amount: GJ' � Amount Paid cL 41&(e , QIP Payment Date ' Payment Type Invoice # Check # 13�j L- Received By: EHO 4"2-025 SR FORM (Golden Rod) REVISED 1111712003