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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 4 2008 SERVICE REQUEST "Type of Businesibderty FACILITY ID # # ExT• cb 3�3- lt7-Z SERVICE REQUEST # �vEL � 512ob 5-31,2-7 OWNER / OPERATOR Q . 1 i v— S -ro n 'A �t � V- E.,1-5 J:7 --c YS `f If BILLING ADDRESS 3 Q FACILITY NAME &V (4 fir() lF SITE ADDRESS Z29 S E R E lilt 0 ► �� S'I` - S To C tG T"0 A( 9S a o S - Street Number Direction Street Name Payme Date city Zip Code HOME or MAILING ADDRESS (If Different from Site Address) - t/ S 6 1- Received By: (S Street Number Street Name CITY Cr7 t 0 W�T-- I t� STATE c a�r ZIP 7 Y PHONE #1 Exr. APN # LAND USE APPLICATION # (S-0 ) 6 s�- 81-00 PHONE #2 Exr. ( ) BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR M' C 14 +^ �/ tA, ! , / r ' � r_` ( CHECK if BILLING ADDRESS BUSINESS NAME I / / L -rl I -4 (1 t �(, " iLJ-PHONE VvC - # ExT• cb 3�3- lt7-Z HOME or MAILING ADDRESS Box FAX # CITY n � STATE �. A- ZIP C/ S-6 Ct l 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 a that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, Standards, STA a d DERAL laws. APPLICANT'S SIGNATURE: DATE: 1 PROPERTY / BUSINESS OWNER ❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT 10 C "-7r " 1 R. A -c Ty h 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. TYPE OF SERVICE REQUESTED: 2 E (f l rzw .- i P IF-�, 6- t COMMENTS: L0 SAN J�PQ�IMENT N0 VjAWA 14 gTMEN HEALTH ACCEPTED BY: EMPLOYEE M DATE: ASSIGNED TO EMPLOYEE #: � DATE: Date Service Completed (if already completed). SERVICE CODE: Fee Amount:2 , d1 Amount Paid �� ti Payme Date \1 \Lk b g Payment Type Invoice # Check # 3 l \ Received By: (S EHD 48-02-025 SR FORM (Golden Rod) REVISED 11/17/2003