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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUESTS . Type of Business or Property FACILITY ID# pSERVICE REQUEST# -775- 2- SI�0C7 5 �S i i OWNER/OPERATOR SPs v /L / O CHECK It BILLING ADDRESS FACILITY NAME TT SI/T/E ADDyIRceeAl ber I Direction Streel Nama Cit Zi Code HOME Or MAILING ADD ESS (lf Different from Site Address) Street Name 6 I Streel Number CITV� O n STAT/E � ZIP c PHONE#1 ExT. APN# LAND USE APPLICATION# PHONE#2 EXT. BOS DISTRICT LOCATIO ODE ( 1 CONTRACTOR / SERVICE REQUESTOR REQUESTOR - CHECK If BILLING ADDRESS BUSINESS NAME PHONE# Ext. HOME or MAILING ADDRESS FAx# I 1 CITY STATE ZIP BILLING ACKNOWLEDGEMENT: 1, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all Site and/or project specific ENVIRONMENTAL FIEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as identified on this form, also certify that I have prepared this application and that the w to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes,Standards, TE an EDERAL la vs. APPLICANT'S SIGNATURE: DATE: PROPERTY/13USINESSOWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT 11 9 /.f APPLICANT is not the BILLING PARTY proof of authorization t0 Sign is required Title - 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 CODNTY 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: IC-00 0 ED COMMENTS: Aug 2 a 2009 SANENsNONNIE SEN . t1EAl-TM DEPP.R ACCEPTED BY: ©Li v/—t EMPLOYEE Al. Q 3 Z( DATE: ASSIGNED TO: -Pei" K"T EMPLOYEE#: 402—r3 DATE: Date Service Completed (if already completed): SERVICE CODE: C)&l P IE: 1602— Fee 60ZFee Amount: aid S' O'� , , Payment Date Payment Type ✓ Invoice# Check# ` � Received By: EHD 4ED 1111 SR FORM Golden Rod REVISED 11/17/2003 ( )