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SAN JOAN COUNTY ENVIRONMENTAL HEALAEPARTMENT SERVICE REQUEST TypWo Busines r Property FACILITY ID # -.77 CHECK if BILLING ADDRESS SERVICE REQUEST OWNUR I OPERATOR b W--Iaj�2 CHECK if BILLING ADDRESS -iJe6 FACILITY NAME J1- HOME or MAIUNgfADDRESSa� SrrE ADDRESS 32tOetNumber I Direction U'�J. be C11* M1 1 OJ bCi Zi Cotle HOME or MAILING ADDRESS (if Different from Site Address) Street Number ACCEPTED BY: Street Name CITY STATE zip PHONE #1 ExT. APN # LAND USE APPLICATION # PHONE #2 EXT. ( ) -T / - ql';s . BOS DISTRICT LOCATION CODE 1. CONTRACTOR SERVICE REOUESTOR REQUESTOR( CHECK if BILLING ADDRESS ::- BUSINESS NAME — r V tjEc PHONE Exr. h._ HOME or MAIUNgfADDRESSa� c - FAX � ) -� C11* STATE zip BILLING ACKNOWLEDGEMENT: 1, the undersigned pr6perty 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 JOAQM COUNTY Ordinance Codes, Standards,,J-TE and FEDERAL laws. APPLICANT'S SIGNATURE: ^ DATE: PROPERTY / BUSINESS OWNER0 OPERATOR/ MANAGER El OTHER AUTHORIZED AGENT 2- If APPLICANT is not the BILLING PARTY, proof ofauthorization to sign is required Titte 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 L1§ .IIrqs g .gqWchnkWenvironmental/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: -RAYAAI�..— COMMENTS: — r V tjEc APR 14 2011 JOAQuIN COUNTY ENViF?ONE NEAL7SAN M NT ARTM ACCEPTED BY: EMPLOYEE #: Y q DATE: LZ ASSIGNED TO: EMPLOYEE #: DATE: Date Service Completed (If already completed): SERVICE CODE: P/E: &3 Fee Amount: Amount Paid Payment Date Payment Type Invoice# . Check # I . �, Lk ft )6 1 Received #y: EHD 48-02-025 REVISED 11/17/2003 SR FORM (Golden Rod)