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2-01 SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID# SERVICE REQUEST# T T6 ad F4 T -5-s6 S 3 OWNER/OPERATOR C CHECK If BILLING ADDRESS FACILITY NAME v SITE ADDRESS G6d 5 ^I,.tE M J CANe !1m �52 'Street Number Direction �-1 K..� lJ SMeet Name W Ci Zi Code HOME or MAILING ADDRESS (If Different from Site Address) reetumer E06 (5ZUo Street Name CITY STATE 1 L TT PHONE#1 ExT. PN* (20 ) �I oy- _ '1 LaND,USEAPPLIC O 0 #T BOS DISTRICT LOCATION CODE C t AF AF CONTRACTOR/SERVICE REQUESTOR REQUESTOR -alre]I OJOUTfeMPb Me), CHECK If BE11M 2LrMg.5a111l w1 bfl6INrR]�PM�5 ON I Eel,) ��l YI - ILLIOExr. BUSINESS NAME PHONE(HOME or MAILING ADDRESS FAX# ( ) �. CITY STATE CA ZIP BILLING ACKNOWLEDGEMENT: 1, the undersigned property or business owner, operator or authorized abent 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: �� DATE: 9-11 -90)0 + PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT S1 '��Vl YG If APPLICANT is not the BILLiNGPARTY,proof of authorization to sign is required Title 1 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: S 7 77--"'n F f /�� f � /),_ ✓ �� COMMENTS: t • PA RECEIVED FEB 12 2010 RUSHI SHRU SAN COON TH DEPARTMENT ACCEPTED BY: O ( L/E i �.o EMPLOYEE#: U DATE; •Z r 2410 ASSIGNED TO: C&C-4-P 1^T- ` EMPLOYEE#: !r f 2Z DATE: Z t10 Date Service Completed (if already completed): SERVICE CODE: ? 9 p/E; Z--g oe Fee Amount: Si-7 S O Amount Paid S ✓l� S C Payment Date Z Payment Type v C Invoice# Check# 5 ij 2 _ 3^y S p Received By: EHD 48-02-025 '4 b o l 2• v SR FORM Golden Rod REVISED 11/17/2003 �� ( )