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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property CHECK If BILLING ADDRESS i, FACILITY ID # SERVICE REQUU/ESOT # Il�t' OWNER / OPERATOR S...f �l II � ✓ p Vr- L-, 5-r C �V ✓�� t' �r ✓L CHECK If BILLING ADDRESS FACILITY NAME r�� S Cj[(�` V /� ., � C�'! `� SITE ADDRESS 2 if I i7 Street Number S Direction IJriGIL i � Tr J Street Name `rf C MI5 7 CO Zi Code HOME Or MAILING ADDRESS (If Different from Site Address)TrLnG� Street Number cel✓ `' Street Name CITY STATE ZIP PHONE #1 EXT. APN # LAND USE APPLICATION # PIiONE42 EXT. ( ) BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REOUESTOR REQUESTOR A `a,+�11 N f-.0 ` 16-7I �• / v CHECK If BILLING ADDRESS i, BUSINESS NAMEPHONE J, i+. 3r' IC -1 f 's -r ( -t C . # Ex-r. Qjl(f SJ Z - 7S-33 HOME Or MAILING ADDRESS/,J,/ L J1 Y ��Lf o� / 'i V l T l,C �'� d FAX# ( ) CITY L � O / V r J V�� STATE C�(� ZIP 015'7 -!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. 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: PROPERTY I BUSINESS OWNER ❑ OPERATOR / MANAGER ❑ OTHER AUTHORIZED AGENT ' (�� * Gl G >< a ✓ If APPLICANT 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 jQTfqrmation t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It IS available and at the Same time It Is providT0V my representative. %V7' TYPE OF SERVICE REQUESTED: COMMENTS: .,uv U 7 1 SAN �j QU/N CO HEAL-rH o 1 yMFNT,4 r ACCEPTED BY: � %� EMPLOYEE #: DATE: ASSIGNED TO: l l �1 EMPLOYEE #: DATE: Q I I Date Service Completed (if already completed): SERVICE CODE: Fee Amount: Amount Paid Payment Date Payment Type Invoice # Check # Received By: EHD 48-02-025 SR FORM (Golden Rod) 07/17/08