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SAN JOAQUWOUNTY ENVIRONMENTAL HEALTHOPARTMENT SERVICE REQUEST Type of Business or Property Ser✓Ice FACILITY ID # G t 3 `t CHECK If BILLING ADDRESS El SERVICE REQUEST # / 3 OWNER/ OPERATOR /j - `e r / _ { j e-- !—C` 7� PHONE # zs-) CHECK If BILLING ADDRESS `!� FACT TY NAME � YI� L C a y7.4 -r c- C Li FAx 1 /SSI SITE ADDRESS Street Number Direction 8 I v Q Street Name ZIP I viz / S - 0& k i-) Ci �G / Zi Code HOME or MAILING ADDRESS (If Different from Site Address) Street Number Street Name CITY STATE ZIP PHONE #1 EXT.APN Lk'? ) �j 3� - /'307 # LAND USE APPLICATION # PHONE #2 EXT. ( ) BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQ9ESTOR � C A4,,:) - (1 /eem Ile `l CHECK If BILLING ADDRESS El BUSIN SS NAME a a.� %trvleu4 PHONE # zs-) ExT. HOME or MAILIN ADDRESS 1176, c' tem rig FAx 1 /SSI V�'J n CITY { � � 1 STATE ZIP I viz 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, STA E and FEDERAL I ws. APPLICANT'S SIGNATURE:iC,( � /' ��2- DATE: C�Jt3%��-- PROPERTY / BUSINESS OWNER ❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT 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 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: US 7— ,-E-1-4,1 IC (% PAYW:1141 COMMENTS: r�EB 15 2012 NViRONMEN COUNTY NTA►- �TM DEPARTMENT ACCEPTED BY: t L) EMPLOYEE #: ^ �� DATE: (S/ ASSIGNED TO: 6 A Gw:-4kS EMPLOYEE #: (p'3 DATE: Z S'' r 2— Date Date Service Completed (if already completed): SERVICE CODE: �1i0 P / E: Fee Amount: ? Z Amount Paid ��s, Payment Date IELI Payment Type Invoice # Check # –T Zl� (� Received By: EHD 48-02-025 SR FORM (Golden Rod) REVISED 11/17/2003