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SAN JOAQUIOOUNTY ENVIRONMENTAL HEALTH IWARTMENT CFRVIC'F. RF01TF.CT Type of Business or Property CHECK If BILLING ADDRESS Y ID # ACCEPTE BY: SERVICE REQUEST # S e r �(k ( e S-A -,;0-- to •'1 r/%' o o CITY PLea-c,6Ln4--e) t -N 51'�'C)0 :5 70 OWNER / OPERATOR DATE: /t ck I o r ^ CHECK if BILLING ADDRESS FACILITY NAME -(0 S��O� PERMIT/SERVICES Fee Amount: j�i ' co SITE ADDRESS ZS T �' Payment Date 2I 2�-V d VA �/ L' t n lei 4 22 Street Number Direction Street Name +[ Zi Co e HOME or MAILING ADDRESS (If Different from Site Address) Street Number Street Name CITY STATE ZIP PHONE #1 EXT. rzc>'u `133---- r3 e-7 APN # �a 30ad�a LAND USE APPLICATION # PHONE #2 EXT. ( ) BOS DISTRICT —/—]F ATnDE CONTRACTOR / SERVICE REQUESTOR REQUTO jCr,L, dee h -!fie lit's t CHECK If BILLING ADDRESS BUSIN SIVAE �J_I Pe--- � ACCEPTE BY: PHONE # EXT. qZS 4� HOME or MAILING ADDRESS (--7(o L4J /J tic 1 }+- FAx# (Gam )) 4 & CITY PLea-c,6Ln4--e) t -N STATE -14 zip C1�cJ� 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, Standard STATE and FEDERAL laws. APPLICANT'S SIGNATURE: DATE: PROPERTY/BUSINESS OWNER❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZEDAGEN'r L7 Cl�-Y') -kC ia- + V r - 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 information to 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: S'� COMMENTS: +( e A no DEC 282009 ENVIRWM Mff HEALTH ACCEPTE BY: 1�o EMPLOYEE #:s�,j DATE: ASSIGNED TO: EMPLOYEE #: �j/vGs DATE: Date Service Completed (if already Completed): SERVVICEE CODE: P / E:,-? Fee Amount: j�i ' co Amount Paid 5 ^, Payment Date 2I 2�-V d Payment Type `� Invoice # Check # rj -2-o D Received By: - EHD 48-02-025 SR FORM (Golden Rod) REVISED 11/17/2003