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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property ` FACILITY ID # REQUEST # Ll�EM�lJT�lC-`� 5ctf.��-- PHONE # EXT. (ISERVICE �1�� OWNER /OPERATOR 2-9 CHECK if p p NiTtrs FCP, p� VN�t 1� 1� x1(-` — �� 5i zC� l 1 BILLING ADDRESS FACILITY NAME Z`(Z t`��Pa,�r C'�2T SITE ADDRESStv�AIJT1 (2,,,j) 239—Fs-k3-1 Ctoi gs33.} Street Number Direction Street Name Date Service Completed (if already completed): CI Zi Code HOME Or MAILING A;;��DD��RESS (If Different from Site Address) Fee Amount: Amount Pai `.7U Street Number Payment Type Street Name CITY PIA CA STATE cit9 Zip s33�o PHONE #1 EXT. APN # LAND USE APPLICATION # ( ) gzS- 3200 2-1 7- ?-to - l, -5o PHONE #2 EXT. ( ) --7 BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR 1 Iv 1 ` CHECK If BILLING ADDRESS BUSINESS NAME PHONE # EXT. l"A C Q- t 1-J C) 2-9 23,7- (,27,2-q HOME or MAILING ADDRESS FAX # ` Z`(Z t`��Pa,�r C'�2T ACCEPTED BY: (2,,,j) 239—Fs-k3-1 CITY lu'\A JTECA STATE L14 ZIP q 33 Q0 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 and FEDERAL laws. APPLICANT'S SIGNATURE: a.4 &2;� DATE: 1 PROPERTY / BUSINESS OWNER ❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT IF �>I N C E(L. If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required Title AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, 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 infpp/��p�ation t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It Is available and at the same time It IS provideiG/lyr my representative. _d617 A TYPE OF SERVICE REQUESTED: .e -K,( -t— .q NI EHD 48-02-025 SR FORM (Golden Rod) 07/17/08 COMMENTS. ti�M,,Ro 1p GAN y�FgR�N�N MFtir ` ACCEPTED BY: EMPLOYEE #: %� v DATE: ASSIGNED T0: EMPLOYEE #: DATE: Date Service Completed (if already completed): SERVICE CODE: 1 E: Fee Amount: Amount Pai ()� Payment Date Payment Type Invoice # Check # / Receiv d By: EHD 48-02-025 SR FORM (Golden Rod) 07/17/08