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SAN JOAQUIN NAUNTY ENVIRONMENTAL HEALTH ISARTMENT SERVICE REQUEST Type of Business or Prope BUSINESS NAME /fi/� w�� !'/^L w/1 FACILITY ID # SERVICE REQUEST # �5 - + CITY STATE ZIP 4 P 2-�1l-S s2oz�� r OWNER / OPERATOR CHECK if BILLING ADDRESS ❑ FACILITY NAME SITE ADDRESS � �s �treet Street Number Direction SName i Zi Code HOME or MAILING ADDRESS (If Different from Site Address) EMPLOYEE Ll 6 Street Number Street Name CITY SERVICE CODE: STATE ZIP PHONE #1 EXT.APN Fee Amount: G C) # 3 LO LAND USE APPLICATION # ria") � 33 - Payment Type Invoice # PHONE #2 EXT. $ (� S Received By: BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR , v CHECK if BILLING ADDRESS �I BUSINESS NAME /fi/� w�� !'/^L w/1 PHONE# p Ems' HOME or MAIL%"DD FAX# CITY STATE ZIP 4 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, S T/E an F RAL laws. APPLICANT'S SIGNATURE: //C'" DATE: 7— tee /O PROPERTY / BUSINESS OWNER ❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT *ter 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: i*L 7 % ENT t COMMENTS: �4 E C EI `I DEC 17 2010 COUNTY jOAOUIN ;.�dVIRONMENTAL DEPARTMENT ACCEPTED BY: C___ EMPLOYEE #:DATE: ASSIGNED TO: EMPLOYEE Ll 6 DATE: Date Service Completed if al eddy Completed): SERVICE CODE: PIE: r3 Fee Amount: G C) Amount Paid 3 LO Payment Date Payment Type Invoice # Check # $ (� S Received By: EHD 48-02-025 SR FORM (Golden Rod) REVISED 11/17/2003