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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DOPPARTMENT SERVICE REQUEST Type of Business or Property /T/r-ViCI T FACILITY ID # BUSINESS NAME\ C --1i SERVICE REQUEST # RECEIVED 'Jthe EXT. HOME or MAILING ADDRESS r OWNER/ OPERATOR l CHECK If BILLING ADDRESS FACILITY NAME , r ' ZIP % s SITE ADDRESS f9 I!^ � C) ! ' yyr(s` r d` � �� ./n -_�7�' Street Number irection Name DATE: /� t Date Service Completed (if already completed): HOME or MAILING ADDRESS (If Different from Site Addles ,) y I PIE: Fee Amount: a Street Number Payment Date a 1' Street Name CITY STATE ZIP PHONE #1 1 EXT. APN # LAND USE APPLICATION # PHONE #2 ( ) EXT. BOS DISTRICT LOCATION CODE I CONTRACTOR / SERVICE REQUESTOR REQUESTOR Ml /T/r-ViCI T CHECK if BILLING ADDRESS BUSINESS NAME\ C --1i J II RECEIVED PHONE# '41) EXT. HOME or MAILING ADDRESS r FAX# SAN JOAQUIN COUNTY CITY STATE ZIP % s 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, TATE and REDERA ls. APPLICANT'S SIGNATURE: Ilk ITl/6' DATE: ` PROPERTY/ BUSINESS OWNER❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required Title J 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 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/r-ViCI T PAYMENT COMMENTS: RECEIVED FEB 2 2 2011 SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT ACCEPTED BY: ' 1%) EMPLOYEE #:�+i S DATE: ASSIGNED TO: EMPLOYEE #: j-64 DATE: /� t Date Service Completed (if already completed): SERVICE CODE: y I PIE: Fee Amount: a Amount Paid3 I Payment Date a 1' Payment Type Invoice # Check # Received By: EHD 48-02-025 REVISED 11/17/2003 SR FORM (Golden Rod)