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_ SAN JOAQU*OUNTY ENVIRONMENTAL HEALTHOPARTMENT SERVICE REQUEST Type of Business or Property CHECK If BILLING ADDRESS FACILITY ID # PHONE # EXT' ~70 SERVICE REQUEST # FAX # CITY 1 , I;. 12-t -i STATE ZIP��f GI SAN JCAQUIN COUNTY SENT f OWNER /OPERATOR C j � - -2� ENVIRONME HEALTH -p D CHECK if BILLING ADDRESS FACILITY NAME EMPLOYEE #: �3 C " (- �— ASSIGNED TO: � SITE ADDRESS. I DATE: Z t7/04Y Date Service Completed (if already completed): (449 Street Number Direction P / E: 23p.0 Street Name 1 s 00 city Zip Code HOME/ orMAILING ADDRESS (If DifferelJ�t from Site Address) ") ' -7101 Payment Type 21�C3 G�w . vt �C ��t_� Street Number Street Name CITY STATE ZIP ri'i269 PHONE #1 EXT. (2,9) 4Z ��72 APN # ✓��w�/ LAND USE APPLICATION # PHONE #2 EXT. (ri/t,) Z� 7- �Zo1 t -..v.:5 ..�c_d� BOS DISTRICTLOCATION Z ODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR CHECK If BILLING ADDRESS BUSINESS NAME• --LL j+ {j�'t-C., Et' T Nc- c1Wa Lvttt- PHONE # EXT' ~70 HOME or MAILING ADDRESS FAX # CITY 1 , I;. 12-t -i STATE ZIP��f GI 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, STA�TEdEDERAL laws. a.7 � APPLICANT'S SIGNATURE: DATE: PROPERTY / BUSINESS OWNER OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT g If APPLICANT is not the BILLING PARTY, proof of authorization to sign is requiredTitle 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: e. ST— v t 1=-A9,d F -C 7- PAYMEN COMMENTS: JUL 17 2009 SAN JCAQUIN COUNTY SENT ENVIRONME HEALTH -p D ACCEPTED BY: EMPLOYEE #: �3 DATE: 7`-I O ASSIGNED TO: � EMPLOYEE #: ?�� DATE: Z t7/04Y Date Service Completed (if already completed): SERVICE CODE: / gpe P / E: 23p.0 Fee Amount: 1 s 00 Amount Paid "l� 3' 5 Payment Date ") ' -7101 Payment Type ✓ Invoice # Check # L. l� lois Received By: EHD 48-02-025 SR FORM (Golden Rod) REVISED 11/17/2003