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SAN JOAQUI*OUNTY ENVIRONMENTAL HEALTAPARTMENT SERVICE REQUEST Types of Business or Property �FjA-CILITY ID # ll 014 BUSINESS NAME S SERVICE REQQUE)STT # 9/ OWNER / OPERATOR 1" _ `, ` CHECK if BILLING ADDRESS FACILITY NAME , a I vT 0 CITY oet STATE 11A ZIP i9S 34, ASSIGNED TO: SITEADDRESS 33,q Street Number ��N✓ Direction ()t S ) 4C4 WI M'f �.t' �, G t'1� Street Name 'f V i :'� city Date Service Completed (if already completed): "7-1'L t; % Zip Code HOME Or MAILING ADDRESS (If Different from Site Address) Street Number Fee Amount: Street Name Amount Paid 41 CITY STATE ZIP f PHONE #1 ExT. ( ) APN # Check # 2 LAND USE APPLICATION # PHONE #2 EXT. BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR -4-3 CHECK If BILLING ADDRESS BUSINESS NAME LO /%'/ PZtco�i J Com' ✓ PHONE# EXT. W "i S /S" - S- � HOME or MAILING ADDRESS FAX # (25) ii�.i 8�lS CITY oet STATE 11A ZIP i9S 34, 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 applic nd th the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, Standards, S T FED L laws. APPLICANT'S SIGNATURE: DATE: D PROPERTY/ BUSINESS OWNER OP TO ANAGER 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. PAYMENT TYPE OF SERVICE REQUESTED: /'s ' l COMMENTS: Co �/v LO /%'/ PZtco�i J Com' ✓ rim MAY 2 8 2008 SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT ACCEPTED BY: / EMPLOYEE #: \ \ DATE: 2 /09 ASSIGNED TO: 6�, C f' 1 U� EMPLOYEE #: 3 DATE: j5(DS Date Service Completed (if already completed): SERVICE CODE: P I E: Fee Amount: Jv Amount Paid 41 Payment Date 5 1'Zg�6g Payment Type f Invoice # Check # 2 Received By: W. �- EHD 48-02-025 SR FORM (Golden Rod) REVISED 11/17/2003