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SAN JOAQU. 'OUNTY ENVIRONMENTAL HEALTI sPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID # SERVICE REQUEST # G i AI L— / c a STATE ZIP CITY c t,4C,0)2- zl' 0 0 �1 -�' t -- --OWNER/ OWNER /OPERATOR ENVIRONMENTAL ❑ I✓Gy �/`A �s � �� (JJL t.% CHECK if BILLING ADDRESS FACILITY NAME ASSIGNED TO: EMPLOYEE #: SITE ADDRESS Z Date Service Completed (if already completed): SERVICE CODE: ZJ' P 1 E: / Fee Amount: S Amount Paid _7� Street Number Direction Invoice # Street Name Check # LF 7� "— City Zip Code HOME or MAILING ADDRESS (If Different from Site Address) /L C T W t�LLry VJI LASS iZj7 Sell r'� C?p,0 Street Number Street Name CITY STATE ZIP 1, r PHONE #1 EXT. APN # LAND USE APPLICATION # b o-zL PHONE #2 ExT. BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR I REQUESTOR 0/� R CHECK If BILLING ADDRESS rj (� rj BUSINESS NAME / PHONE # EXT. HOME Or MAILING ADDRESS '' °e, �^ r Vv T `V L,J E � t -L FAX # ( ) / c a STATE ZIP CITY c t,4C,0)2- 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 . TATE and F DERAL wS. APPLICANT'S SIGNATURE: DATE; � Z PROPERTY/ BUSINESS OWNER❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT N1 A?� 1TEL7 IfAPPLICANT 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 t0 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: COMMENTS: RECEIVED JUN 18 2012 SAN JOAQUIN COUNTY ENVIRONMENTAL NFALTH DFPARTMEN-'' ACCEPTED BY: EMPLOYEE #: DATE: ASSIGNED TO: EMPLOYEE #: DATE: Date Service Completed (if already completed): SERVICE CODE: ZJ' P 1 E: / Fee Amount: S Amount Paid _7� Payment Date Payment Type ✓ Invoice # Check # LF 7� "— Received By: let EHD 48-02-025 SR FORM (Golden Rod) REVISED 11/17/2003