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11 Ll SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID # SERVICE REQUEST # ACCEPTED BY: EMPLOYEE M OWNER/ OPERATOR CHECK If BILLING ADDRESS DATE: Date Service Completed (if already completed): FACILITY NAME SERVICE CODE: J Fee Amount: SITE ADDRESS N I V, Payment Date Payment Type 9 SZ® �. LA5 Street Number Direct,. \ City Zip Code HOME or MAILING ADDRESS (If Different from Site Address) Street Number Street NM a „® CITY ^� 1.7 ft®`s�c5� STATE ZIP -T-)(I -7 S 20 Z PHONE #1 EXT. APN # LAND USE APPLICATION # fa%%4) SS -e+ -`oq 0 PHONE #2 EXT. ( ) BOS DISTRICT LOCATION CODE 01 CrrVW rIJ:4&1131►ai'Lai 1s;1 x911) AL REQUESTO'R�a^ t r T ` CHECK If BILLING ADDRESS BUSINESS N A""C �. PHONE # EXT. i`t•s `lkrotyt.XEt1L-r,,l T__ P --,j ec mss., 7Z NC_- _(`da -Loa HOME or MAILING ADDRESS FAX # ` ( (` 9 ) CITYr^a _STATE a 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❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT Jc�vn�R.CC `1 1 �CWe0.q„L�„� 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. A-, n TYPE OF SERVICE REQUESTED: COMMENTS: ACCEPTED BY: EMPLOYEE M DATE: ASSIGNED TO: EMPLOYEE M DATE: Date Service Completed (if already completed): SERVICE CODE: P / E: C� Fee Amount: Amount Paid Payment Date Payment Type Invoice # Check # Received By: EHD 48-02-025 SR FORM (Golden Rod) REVISED 11/17/2003