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SAN JOAQUINr'OUNTY ENVIRONMENTAL HEALTH EPARTMENT 0 SERVICE REQUEST r Type of Business or Property FACILITY ID # BUSINESS NAME \ �r a o l �eum SERVICE REQUEST # C OF. Fe, 6- -7 CITY %') q -k c ',p �OU535� OWNER/ OPERATO (J el i e— �� a— CHECK If BILLING ADDRESS FACILITY NAM k_aN -T SITE ADDRESS DATE: Date Service Completed (if a ready completed): �i SERVICE CODE: l 91' Street Number Direction Street Name Amount Paid 01. }�, Payment Date 3 ( �S i o O Zi Code HOME or MAILING ADDRESS (If Different from Site Address) Check # 1 Street Number Received By: Iv Street Name CITY STATE ZIP EXT. PHONE #1 APN # LAND USE APPLICATION # nn PHONE #2 EXT. ( ) BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR O % , L 0' VL (�/ CHECK if BILLING ADDRESS ❑ BUSINESS NAME \ �r a o l �eum PHONE EXT. r✓(`C�s� ( ) �q5- &5L � ROME Or MAILING ADDRESS ,5� 1 BrAfd-i �2'j'� (d ) / _ J o CITY %') q -k c ',p STATE ZIP s C /„ 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, Standar TATE and FED laws. �% APPLICANT'S SIGNATURE: / 1Lt/ DATE -6 -�% -/� ^�' PROPERTY / BUSINESS OWNER 13OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT ® ('ffo71nk e�&oe- - 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 Drovided to me or my representative. U'S % (7— TYPE OF SERVICE REQUESTED:'Q i if 13 L kr / COMMENTS: �i` l SP( L 25 (A 0: e- ('�n MAR 1 3 ZOU8 SAN JOAQUIN COUNTY ENVIRONMENTAL ACCEPTED BY: © t c. G L.�C ✓�—�9— EMPLOYEE #:�"; 3 f jLTHP rT C ' ASSIGNED TO: (�� EMPLOYEE#: y DATE: Date Service Completed (if a ready completed): SERVICE CODE: l 91' PIE: —2-36,0 Fee Amount: ��• L'Z. Amount Paid 01. }�, Payment Date 3 ( �S i o O Payment Type ✓ Invoice # Check # 1 Received By: Iv EHD 48-02-025 SR FORM (Golden Rod) REVISED 11/17/2003