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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or P operty Jr)�611 �- t� � K FACILITY ID # fpaoo2� CHECK If BILLING ADDRESS SERVICE REQUEST # OWNER /O ERATOR / 401 M.// IMT CHECK if BILLING ADDRESS FACILITY NAME/ 1�57—Z_G�C, C (� FAX#, (%/CJ) SITE ADDRESS r LO Number Direction e�" �'Gt/I r_✓T"t � Street Name L L-' n' CI q (S Z�L ZIP Coda HOME or MAILING ADDRESS (If Different from Site Address) Street Number Street Name CITY STATE ZIP PHONE#1 ERr. t ) APN# LAND USE APPLICATION# PHONE #2 EXT. ( ) BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR RET/)C� m bon e- /// TOR CHECK If BILLING ADDRESS Bus i NAME Mms PE0� �� ,mss PHONE# I' Ez, _;7J7 HOMEor MA ILINGiILDQRESS' /_ "!l L� C.CC— FAX#, (%/CJ) ?C'Sr' VCJ/ ZOOO CITY 5'�n24Y,K e It XV � STATE ZIP 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 perform will be done in accordance With all SAN JOAQUIN COUNTY Ordinance Codes, Standards, FEDERAL laws. _ APPLICANT'S SIGNATURE: �� DATES: PROPERTY / BUSINESS OWNER ❑ OP TOR / MANAGER ❑ OTHER AUTHORIZED AGENT la V op if 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 as My I mfnformation t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it IS available and at the same lime It99?# r ,,"e or my representative. , ' I` -1c. E l V e_ , -t TYPE OF SERVICE REQUESTED: COMMENTS: U(� ACCEPTED BY: ASSIGNED TO: Date Service Completed (If already completed): Amount: 2-1`6 I Amount Payment Type 1/; ,iI Invoice # EHD 48-02-025 07/17!08 NOV I s �Ai9 SAN JOAOUIN COUPiTy ENVIgOMENTAL HEALTH DEPARTMENT EMPLOYEE DATE: I I (V EMPLOYEE#: DATE: t Ie 'V SERVICECODE: s6,5a3 PIE: 3tQ62' rPayment Date I tOdk # D`f37(-7 Received By: SR FORM (Golden Rod)