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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID # SERVICE REQUEST # OWNER / OPERATOR n I P4 rna Wk � &,ra tt t� epe T S'` � CHECK IfBILLING ADDRESS FACILITY NAME CT I 1t SITE ADDRESS y k(3 & Po •u � � / �jrat , ,Street Number Dire :t7ion Street Name C Ci Z43 Code HOME or MAILING ADDRESS (If Different from Site Address) Street Number Street Name CIN STATE ZIP REQ FAI � PHONE 91 EXT. APN # LAND USE APPLICATION # ` V /, 6 PHONE #2 EXT- BOS DISTRICT LOCA e�glr 0 ?02 ( ) y NVIR 4U/N CUN o CONTRACTOR / SERVICE REQUESTOR p�pI Ifx /VT /� REQUESTOR L`� V ci� 4a +L Sb.�N e Lk e. 2• CHECK if BILLING ADDRESS 0 BUSINESS NAMEPHONE # EXT• Ib IatutunZ P9401 /2 S rt. , Ct ,5 2 . C _ arY , 0 HOME or MAILING ADDRESS FAx # io I C 'fi ( ) ,� o C STATE 4' A zip Y ,r^Q CT , Tn' t 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, STATE and FEDERAL laws . J APPLICANT'S SIGNATURE : DATE : O 7o S — Z-o 20 PROPERTY / BUSINESS OWNER OPERATOR / ANAGER ❑ OTHER AUTHORIZED AGENT ❑ If APPLICANT S 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 t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it Is provided t0 me Or my representative . TYPE OF SERVICE REQUESTED : S Roe t COMMENTS : "�j1G � p� lc te�� C 1C P5 T tnQ -CnG I1j L � CtJ 3 "FD + 1 Y�r4N1� fl c✓ G rlet c� > ( �S S Q� v t N � I � 0 Al J V , � .i I ((t' lC(G � � V1.� �A `7v Or^2 vis a ✓ a �Lt9 T " CU h1 C4 ," A a IC ACCEPTED BY: , / EMPLOYEE #: DATE: ASSIGNED TO : S �) v EMPLOYEE # : DATE: Date Service Completed (if already compI ERVICE CODE : / qS, I PIE: 200 Fee Amount : `7- � V0Amount Paid LLCT%J Ol � � Payment Date 11512F') Payment Type � � Invoice # Check # ' �lo Received By: EHD 48-02-025 SR FORM (Golden Rod) 07/ 17/08