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SAN JOAQUIN JUNTY ENVIRONMENTAL HEALTH _ 'ARTMENT SERVICE REQUEST Type of Business or Property CILITY ID # CHECK if BILLING ADDRESS❑ SERVICE REQUEST # etc. 1 EXT. 3� -lrri HOME or MAILING ADDRESS P $off tmzr RErtA,IL CaSoLIN'I'-- FAX # (9�6) 3�3 3jJ (" c =i (-q I OWNER / OPERATOR CHECK if BILLING ADDRESS ❑ ILL � C)aG FACILITY NAME E2 00 l-% LL -T SITE ADDRESS E w�-r E2 L o o 2 D- L t �, G l (1 ,Q S ro C << T-0 t`i 9 s- t 3 / Street Number Direction Street Name DATE: f -6 C) Cit Zi Code HOME or MAILING ADDRESS (If Different from Site Address) P / E: 2 104, Fee Amount: - Street Number Amount Paid Street Name CITY STATE ZIP PHONE #1 EXT. ( 1 APN # LAND USE APPLICATION # PHONE #2 EXT. BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR t C %A A-rz,� v ^1 L t -T— 101 "9 11- CHECK if BILLING ADDRESS❑ BUSINESS NAME E, �c(.II AL1'ofd E�lr-E2r.,tii etc. PHONE # qr% EXT. 3� -lrri HOME or MAILING ADDRESS P $off tmzr FAX # (9�6) 3�3 CITY R P -G 4 w, t�-w�-o STATE C j�- !'' ZIP y r 6 9 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 a FED AL laws. APPLICANT'S SIGNATURE: DATE: PROPERTY / BUSINESS OWNER❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT 9 C C "t T R Li -t; rQ r,-- ff APPL/CANT 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 ,;A A 4n n P nr my rPnrPCPntntlVP.. TYPE OF SERVICE REQUESTED: L t -T— 101 "9 11- RECEIVED COMMENTS: APP 2 U 2006 SAN JOAQUIN COUNTY ENVIRONMENTAL HEALT ACCEPTED BY: L t �, G l (1 ,Q EMPLOYEE #: 0 ?) Z r DATE: 2-0 0 ASSIGNED TO: (_� EMPLOYEE #: S ` DATE: f -6 C) Date Service Completed (if already completed): SERVICE CODE: j P / E: 2 104, Fee Amount: - 2 -71 . L-l� Amount Paid rl S Payment Date LA I L6 6 Payment Type Invoice # Check # 2, Received By: G EHD 48-02-025 SR FORM (Golden Rod) REVISED 11/17/2003