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SAN JOAQUI*OUNTY ENVIRONMENTAL HEALTIIOPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID # SERVICE REQUEST # BUSINESS NAMEY, 3too�ee D��zO/ HOME or MKJNG ADDRESS To MAR 3 1� QUW Coutyv SNes',\FkpEPZ EST FAX # OWNER /OPERATOR , / /'� ,//j l �5) "��W N 1 ✓ L � � r� �7 �-C%f OR CHECK N BILLING ADDRESS ❑ FACILITY NAME r, DATE: c3 3a �i ASSIGNED TO: SITE ADDRESS lYl�=!�6-� DATE: '�✓5�� Street Number Direction /✓/ Street Name Fee Amount: DO C' Zi Code HOME or MAILING ADDRESS (If Different from Site Address) Invoice # Street Number Street Name CITY STATE ZJP PHONE #1 ExT.APN # LAND USE APPLICATION # (909) 4- SSS PHONE R Err. BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR % CHECK if BILLING ADDRESS BUSINESS NAMEY, PHONE # /S 3 ExT' HOME or MKJNG ADDRESS To MAR 3 1� QUW Coutyv SNes',\FkpEPZ EST FAX # CITY CSFB, STATE �� ZIP c ��3 M BILLING ACKNOWLEDGEMENT: 1, 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 JOAQUI N COUNTY Ordinance Codes, Standards STATE and F ERAL laws. APPLICANT'S SIGNATURE: DATE: PROPERTY / BUSINESS OWNER ❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT 14 �.6►�✓,-/�y, 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. ^ r%nVBENT TYPE OF SERVICE REQUESTED: er'W;r-/ % RECE1 COMMENTS: To MAR 3 1� QUW Coutyv SNes',\FkpEPZ EST ACCEPTED BY: LQuf EMPLOYEE #: Qo �� ` DATE: c3 3a �i ASSIGNED TO: /3/�FY e► EMPLOYEE #: '3� DATE: Date Service Completed (if already Completed): SERVICE CODE: ! 4� P 1 E: a 6� Fee Amount: DO Amount Paid 13 (p (o O -0 Payment Date ✓? 3; j Payment Type Invoice # Check # 1132,8- Received By:� EHD 48-02-025 do �r SR FORM (Golden Rod) REVISED 11/17/2003 E