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i r • SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property CHECK If BILLING ADDRESS Er FACILITY ID # SERVICE REQUEST # OWNER/ OPERATOR Op CHECK If BILLING ADDRESS FACILITY NAME HOME or MAILING AYDREfSSf JR SITE ADDRESS c2qo O Street Number Direction Be, BeJ� 1N H61,+— Street Name (71 ) Sld3 - Zai STOC/C 7v city �20 % Zip Code HOME or MAILING ADDRESS (If Different from Site Address) Street Number r�WE Street Name CITY ASSIGNED TO: STATE ZIP PHONE #1 EXT. APN # DATE: LAND USE APPLICATION # PHONE #2 EXT. P 1 E: d� BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR CHECK If BILLING ADDRESS Er BUSINESS NAME/ PHONE # Ext. C.! GI A ' Se/Y//c a— ci / HOME or MAILING AYDREfSSf FAX # - it (71 ) Sld3 - Zai CITY 1.3 kem f STATE d4 ZIP 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: DATE: PROPERTY/ BUSINESS OWNER ❑ ERATOR ER ;a ---OTHER AUTHORIZED AGENT If APPLICANT i n e BILLING PARTY, proof of authorization to sign is required lqc ATi tl a 14AVA1 yL 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: u5>" AV KAT COMMENTS: FtECENE ark 1 2011 TM SXN EtCOUN 4VIRONMENTA HE�1LTYl DEPARTMENT ACCEPTED BY: r�WE EMPLOYEE #: Q0 66 DATE: �! �/ ASSIGNED TO: C— G�uJr EMPLOYEE #: 3b DATE: Date Service Completed (if already completed): SERVICE CODE: (I ff P 1 E: d� Fee Amount: '3'6,'6 QO Amount Paid b� , _ Payment Date `k Payment Type v Invoice # Gheek# O (� s 3 1 Received By: (\[r, CQV\* EHD 48-02-025 SR FORM (Golden Rod) REVISED 11/17/2003