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SERVICE REQUEST Type of Business or Property FACILITY ID # SERVICE REQUEST # , CENED COMMENTS: OWNER/ OPERATOR JUN 15 2012 sAri7oAaun+ ca�rtra'.-. _. HEALTH OEPARTIAENT ACCEPTED BY: yr/ r / CHECK If BILLING ADDRESS FACILITY NAME C U SITE ADDRESS `'�I � • rp �,�� 1� f, � , 'STrreet X1.11 DATE: Street Number Direction SERVICE CODE: Name Fee Amount: ' _ �� . Zh'2 Code HOME Or MAILING ADDRESS (If Different from Site Address) Payment Type Inv i� 1 ` Street Number Street Name CITY STATE. ZIP PHONE #1 ExT• ( 2aw ��t3- lam APN # LAND USE APPLICATION # PHONE #2 ExT• BOS DISTRICT LOCATION CODE REQUESTOR i BUSINESS NAME C� HOME Or MAILING ADDRESS CITY CONTRACTOR / SERVICE REQUESTOR L5 � W �LtAA� �rX�1 CHECK If BILLING `ADDRES PHO E Exr.. FAx # ( 25q) STATE CJ4 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 be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, Standards,. STATE and FEDERAL laws. APPLICANT'S SIGNATURE: DA PROPERTY / BUSINESS OWNER❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT 5 Uf1j(I�t 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: CENED COMMENTS: c JUN 15 2012 sAri7oAaun+ ca�rtra'.-. _. HEALTH OEPARTIAENT ACCEPTED BY: yr/ r / EMPLOYEE #t DATE: ASSIGNED TO: Gl / J EMPLOYEE #: DATE: Date Service Completed (if already. completed): SERVICE CODE: P I E: U Fee Amount: ' _ �� . mount Paid l� 7>'_S `( I, Payment Date Payment Type Inv i� Check # Received By: EHD 48-02-025 REVISED 11/17/2003 RECEIV �� SUN � 8 2012 SAROS'A" L Hk TtA DEP#R ( C) SR FORM (Golden Rod)