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.JAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT • SERVICE REQUEST . Type of Business or Property BUSINESS NAME Kill A' FY2- b l :7� N C_ FACILITY ID # HOME Or MAILING ADDRESS SERVICE REQUEST # ORS 4 60/vvemewc.E SToier 2 '-13 -7 / OWNER / OPERATOR J �n^� CHECK If BILLING ADDRESS �/� r (� E (,, V DATE: ZO D U FACILITY NAME � / /I -4 SITE ADDRESS &-;09 VV r H/1,'',(0EIZ c/ IlJ 1 /V �Ci � 2-1 Street Number Direction Street Name Zip Code HOME�� or MAILING ADDRESS If Different from Sit Address) Amount Paid �U �//t Li 0 Lf Street Number Street Name CITY �^ Q STATE ZIP PHONE #1 EXT. APN # LAND USE APPLICATION # PHONE #2 EXT. ( ) BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR CHECK If BILLING ADDRESS BUSINESS NAME Kill A' FY2- b l :7� N C_ PHONE # EXT' ( ) HOME Or MAILING ADDRESS FAX # CITY STATE 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: /orJ A -JJ PROPERTY/ BUSINESS OWNER (2P OPERATOR / MANAGER OTHER AUTHORIZED AGENT El 0'.0rlJL�1� If APPLICANT is not the BILLING PARTY, pro 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 av is lable-at!�Pt the same time it is provided to me or my representative. PAr-F IV ECS TYPE OF SERVICE REQUESTED: US T 6cy�lJ 0 COMMENTS: A SAN JOAQUIN COUNTY AL ENVIFIONME HEALTH ACCEPTED BY:/, w� EMPLOYEE #: 3 DATE: ZO D U ASSIGNED TO: ��, EMPLOYEE #: ?` DATE: 20 Date Service Completed (if already Completed): SERVICE CODE: Ob PIE' 2?1 Fee Amount: Amount Paid �U Payment Date U -f Payment Type Invoice # Check # Received By: -Zo� EHD 48-02-025 SR FORM (Golden Rod) REVISED 11/17/2003