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SAN JOAQUIUNTY ENVIRONMENTAL HEALTzT�EPARTMENT 0 SERVICE REQUEST Type of Business or Property CHECK If BILLING ADDRESS FACILITY ID # Lac SERVICE REQUEST # �; A S -C-'? T1 CM RI=CE, NItu 2 f 2-- CITY f� O 01 AUC 0Q51 OWNER / OPERATOR 1^ v �� n r �� 1 L- l/ CHECK If BILLING ADDRESS ❑ FACILITY NAME SA►EAQUIN COU�4T*� -T N SITE ADDRESS NOVIRONME HATH DEPAR ACCEPTED BY: - 1 EMPLOYEE #: l.� DATE: dp3Ih D "r Street Number Direction► EMPLOYEE #: Street Name DATE: ! tf Y--? Ci Zip Code HOME or M (LING ADDRESS (if Different from Site Address) `f / (7- PIE: �3 I Fee Amount: / t/ t -l.— Street Number Street Name CITY 9,©J U I LL (--STATE Payment Type PHONE fl ExT. ApN # LAND USE APPLICATION # 2 � ^� �� EXT. N BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR r J-� LL � � CHECK If BILLING ADDRESS BUSINESS NAME osSPtuE t��F_s��( r.S Lac p NE ExT. (iii 7`��- 77y HOME or MAILING ADDRESS s-rU� � CT: RI=CE, NItu FAX ( asp as e7 CITY f� O 01 AUC STATE c-ln� ZIP S-�7,Q , 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, ST E a FEDE L laws. APPLICANT'S SIGNATURE: DATE: 3 /A v PROPERTY/ BUSINESS OWNER ❑ OPERATOR / MANAGER O 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: t'ii S / c O tis ct C-`%`--4 '7 pa ENT COMMENTS: RI=CE, NItu AUG 3 ZOta SA►EAQUIN COU�4T*� -T N NOVIRONME HATH DEPAR ACCEPTED BY: e C CV 1 ,n _/ EMPLOYEE #: 032-( 3L DATE: dp3Ih D ASSIGNED TO: L( —jrSERVICE EMPLOYEE #: Z DATE: ! tf Y--? Date Service Completed (if already completed):CODE: PIE: �3 I Fee Amount: Z Z Amount Paid Payment Date Payment Type Invoice # Check # Received By: EHD 48-02-025 SR FORM (Golden Rod) REVISED 11/17/2003