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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property C,nrne�ca� /�D� FACILITY ID # FA UUGOd SERVICE REQUEST # S(ZOO S-76 4� OWNER / OPERATOR CHECK It BILLING ADDRESS FACILITY NAM PHONE 11 E� . a0.7?� 9 a a/ 3z SITE ADDRESS /7;1 Street Number Direction I✓'ef �' � /[� Street Name CITY ! �-�-i (�[�`Oi� C �7 X37 2i Code HOME or MAILING ADDRESS (If Different from Site Address) a+ o¢� �1� � 0 ✓, �' f e 54, � Street Number Street Name CITY �j "f STATE PHONE #1 ET. ( I APN # LAND USE APPLICATION # PHONE #2 ExT ( I BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR r n (/ CHECK if BILLING ADDRESS r r/ BUSINESS NAME PHONE 11 E� . a0.7?� 9 a a/ 3z HOME ��LINGADDRESSA / FA%# CITY ! TATE 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, ST and FEDERAL laws. APPLICANT'S SIGNATURE: DATE: 7 / 7- o PROPERTY/ BUSINESS OWNER EI OPERATOR/MANAGER ❑ THER AUTHORIZED AGENTFIY IfAPPLICANr 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: r COMMENTS: P Y RECEIVED JUL 17 2009 SAN JOAOUIN COUNTY ENVIRONMENTAL nEPARTMAENT ACCEPTED BY: EMPLOYEE #: DATE: v ASSIGNED TO: EMPLOYEE#: DATE: Date Service Completed (if already Completed): SERVICE CODE: "i P i E: D Fee Amount: o Amount Paid 'EkDD -C� Payment Date O Payment Type ✓ Invoice # Check# 3 7 Received By: EHD 48-02-025 REVISED 11/17/2003 SR FORM (Golden Rod)