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2-v9 SAN JOAQUI OUNTN' ENVIRONMENTAL HEALTH PARTNtENT SERVICE REQUEST Type of Business or Property FACILITY ID # 'D— SERVICE REQUEST # SK OC) C2 OWNER / OPERATOR Mb CHECK if BILLING ADDRESS FACILITY NAME , ^ HOME or MAILING ADDRESS SITE ADDRESS ", O1 Street Number E ° Direction (t ljIRKIE a \ Street Name ZIP 9052,65 STATE CA Ci Zip Code HOME or MAILING ADDRESS (If Different from Site Address) Street Number Street Name ACCEPTED BY: CITY EMPLOYEE #: STATE ZIP ASSIGNED TO:�f PHONE #1 EXT. ( ) EMPLOYEE #: API # LAND USE APPLICATION # ady completed): PHONE #2 Ex -r. ( ) SERVICE CODE: BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR aJx11('60Vfe=Pb CHECK if BILLING ADDRESS Me) BUSINESS NAME ELM M CONUM6 M, Mb PHONE & -y EXT. 14W -455 1 FAX # HOME or MAILING ADDRESS UIJOAON C� (2,M) '*11 CITY ZIP 9052,65 STATE CA BILLING ACKNOWLEDGENIENT: 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: Ili V DATE: PROPERTY / BUSINESS OWNER❑ OPERATOR/ MANAGER ❑ OTI'IER AUTHORIZED AGENTS] IfAPPLICANT is not the BILLING PARTY, proof of authorization to sign is required Tule AUTHORIZATION TO RELEASE INFORNIATION: 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: DOME COMMENTS: - � 2011 1 1UN UIJOAON C� SA EN�IR pEPAR�ENT H�-TM ACCEPTED BY: EMPLOYEE #: DATE: ASSIGNED TO:�f EMPLOYEE #: DATE: Date Service Completed (if ady completed): SERVICE CODE: nnn P 1 E: Fee Amount: Amount Paid Payment Date (o Payment Type Invoice # Check # 3 Receive By: EHD 48-02-025 SR FORM (Golden Rod) REVISED 11/17/2003