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SAN JOAQ 4 COUNTY ENVIRONMENTAL HEALTI EPARTnIENT SERVICE REQUEST Tyof Business or Property , l FACILITY ID # �0 ^ Ex? �0/ SERVICE REQUEST # 6 Z OWNER I OPERATOR \ 1 I / V l STATE CITY rxu CHECK if BILLING ADDRESS E] r r,� „ FACILITY NAMYVII `-� 119 n tY MAY - 7 2012 SITE ADDRESS Street Number I Direction Street Name Ci Zi Code HOME Or MAILING ADDRESS (If Different from Site Address( Street Number ACCEPTED BY: — Stre¢t Name CITY STATE ZIP PHONE #1 EXT I 1 ' APN # PLAND USE APPLICATION # PHONE #2 E+T• ( 1 ASSIGNED TO: VL DISTRICT LOCATION CODE CONTRACTOR / SERVICE REOUESTOR REQUE OR � CHECK It BILLING ADDRESS BUSINESS ME^ ^ Ex? �0/ HOME or MAILING ADDR SS/ V ( I `11 E7 I CZIJP STATE CITY rxu 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 10AQUDN COUNTY Ordinance Codes, Standards, STAT and FE ORAL laws. APPLICANT'S SIGNATURE: DATE: _115/:7 PROPERTY/ BUSINESS OWNER❑ OPERAT 71Y .ANAGER ❑ 0TRER AUTHORIZED AGENT ❑ I /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 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 sante time It is provided to me or my representative. TYPE OF SERVICE REQUESTED: 6 L , ,,, PAEN-f COMMENTS: MAY - 7 2012 ,QUIN COUNTY 'OHVFWT r. 3EpARTMENT ACCEPTED BY: — EMPLOYEE#: cleDATE: Z ASSIGNED TO: VL EMPLOYEE#: r— 2I DATE: Date Service Completed (if already completed): SERVICE CODE: 52 P I E: j O 2 Fee Amount: Amount Paid vc — Payment Date t Payment Type Invoice # Check # < s7 Received y: EHD 48-02-025 REVISED 11/17/2003 SR FORM (Golden Rod)