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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST type of Business or Property CHECK If BILLING ADDRESS WW FACILITY ID # SERVICE REQUEST # BUSINESS NAMEPHONE COMMENTS;ENVIRONA # EXT. AMY C HOME or MAILING ADDRESS,A K FAX# OWNER / OPERATOR CITY `�!/ < STATFG.' ZIP #: DATE: C ECK If BILLING ADDRESS Ax FACILITY NAME ASSIGNED TO: /j� !f/ /� �)7 EMPLOYEE SITE ADDRESSj ver Date Service ICompleted ") G� i^ d> < / �� ` lCi(J fiya. , L�� Ace)4 E: Fee Amount:, ; / �` C `T Street Number Direction Payment Date $ / 5d2.9ffeet Name;PW Invoice # fi e HOME or MAILING ADDRESS (If Different from Site Address) Received By: Street Number Street Name CITY STATE ZIP PHONE #1 Ex -r. APNN # LAND USE APPLICATION # ( ) l zu W l PHONE #2 ExT• BOS DISTRICT LOCATION CODE ( ) 00 CONTRACTOR /SERVICE REQUESTOR REQUESTOR , BILLING ACKNOWLEDGEMENT: I, the undersigned propert V / 4 GJ 4,-1 CHECK If BILLING ADDRESS WW BUSINESS NAMEPHONE COMMENTS;ENVIRONA # EXT. HOME or MAILING ADDRESS,A K FAX# !'t . CITY `�!/ < STATFG.' ZIP #: DATE: j _/ y 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. 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 an AL la APPLICAN 'S SIGNATURE: L.L Ty DATE.. I PROPERTY / BUSINESS OWNER tJ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENJAa O L/ /`G 4r. 0/0�% /f 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 t'P" �IEi�Ir site address; hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment i r t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It Is available and at the same time It IS provide�FIVMU my represe TYPE OF SERVICE REQUESTED: IENTAL COMMENTS;ENVIRONA bEALTH DEP C ACCEPTED BYS EMPLOYEE #: DATE: j _/ ASSIGNED TO: /j� !f/ /� �)7 EMPLOYEE #: DATE: Date Service ICompleted (if already completed): SERVICE CODE: 2g� P / E: Fee Amount:, ; / �` C `T Ll Amount Paid S Payment Date $ � 24 Payment Type Invoice # Check # l V Received By: EHD 48-02-025 SR FORM (Golden Rod) 07/17/08 I COUNTY 1RTMENT