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SAN JOAQUIN C NTY ENVIRONMENTAL HEALTH DI ZTMENT SERVICE REQUEST Type of Business or Property FACILITY ID# SERVICE REQUEST# I^dtlta,," o o Zo 9- �IRLOb w) 3 OWNER/OPERATORS L r S � n CHECK If BILLING ADDRESS FACILITY NAME �/ SITE ADDRESS ��yyt m o S S�'o ala,•. q -Z I z 3206 Street Number Direction treet Name Cit Zi Code HOME or MAILING ADDRESS (If Different from Site Address) Street Number Street Name CITY STATE ZIP PHONE#1 ExT. APN# LAND USE APPLICATION# PHONE#2 ExT. BOS DISTRICT LOCATION CODE ( ) CONTRACTOR / SERVICE REQUESTOR REQUESTOR -TO N -f S(�G I� 1 I CHECK If BILLING ADDRESS BUSINESS NAME (- I / f� PHONE# ExT. Coy\- (r,e..M� e-•f lJ�n�wW1 0 HOME Or MAILING ADDRESS �7�^1 � A /�I _ / FAX# CITY N v STATE ZIP BILLING ACKNOWLEDGE ENT: 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 FtULRAL laws. APPLICANT'S SIGNATURE: DATE: 01 h -0 I PROPERTY BUSINESS OW �6 OPERATOR/MANAGER ❑ OTIIF.R AUTHORIZED AGENT❑ L/CANT is not the BILL/NG 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. PAYMEN TYPE OF SERVICE REQUESTED: v �Cay� ( Q (_ RECEIVED COMMENTS: JUL 1 p 2013 SAN JOAQUIN COUN ENVIROMENTAL HEALTH DEPARTMENT ACCEPTED BY: AA, AJ,410-Ll- EMPLOYEE#: ;�/ 70 DATE: -7// 3 ASSIGNED TO: I^a n'` EMPLOYEE#: I ogif DATE: -71toll 3 Date Service COmKletd (if already complete SERVICE CODE: � Z 7 PIE: (10UFee Amount: Amount Paid Payment Date Payment Type Invoice# Check# Z 9 Received By EHD 48-02-025 SR FORM(Golden Rod) REVISED 11/17/2003