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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property T• BUSINESS NAME I A�OGI &raF5 PHONE # EXT. _ 3 (oS FACILITY ID # SERVICE REQUEST # CITY Cin 0<7V / it STATE ZIP O5 jrj SAN JOAQUIN COUNTY OWNER / OPERATOR • ENVIRONMENTAL CHECK If BILLING ADDRESS � � FACILITY NAME , o i► /lW(L600`I, EMPLOYEE #: DATE:7 SITE ADDRESS 02 L A�ere EMPLOYEE #: DATE: 7 _ O50 Date Service Completed (i already completed): Street Name SERVICE CODE: 5 2 Ci Zi Co e HOME Or MAILING ADDRESS (If Different from Site Address) Amount Paidy �;7 .� Street Number Street Name CITY Invoice # STATE ZIP PHONE #1 ( EXT• APN # 1 � ) :2-D LAND USE APPLICATION # PHONE #2 ( ) EXT. BOS DISTRICT c- LOCATION CODE 4!r�1 CONTRACTOR / SERVICE REQUESTOR A _ T REQUESTOR� ` I,��E B06 -ALT `/1/ (/(�, CHECK If BILLING ADDRESS T• BUSINESS NAME I A�OGI &raF5 PHONE # EXT. _ 3 (oS HOME or MAILING ADDRESS 5 15,*&01Ncrn 4-wi - FAX # (gds) 3 - 0/'7& CITY Cin 0<7V / it STATE ZIP O5 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 appli atio and that the rk to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, Standards, STAT and EDERAL la APPLICANT'S SIGNATURE: DATE: - 7/70/a PROPERTY I BUSINESS OWNER ❑ OPERATOR 4ANAGER ❑ OTHER AUTHORIZED AGENT L"J Fmee ( oelu r If APPLICANT IS not the BILLING PARTY, proof of au horization 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. a TYPE OF SERVICE REQUESTED: COMMENTS: SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT. ACCEPTED BY: EMPLOYEE #: DATE:7 / k ASSIGNED TO: h EMPLOYEE #: DATE: 7 _ O50 Date Service Completed (i already completed): SERVICE CODE: 5 2 PIE: Fee Amount: �� Amount Paidy �;7 .� Payment Date Payment Type Invoice # Check # Received By: , EHD 48-02-025 SR FORM (Golden Rod) 07/17/08