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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPAR'T'MENT SERVICE REQUEST Type of Business or Property FACILITY ID # SERVICE REQUEST # HOME or MAILING ADDRESS [—IkVS 83`70.7 OWNER /OPERATOR CIN '` STATE ( n ZIP -� c CHECK if BILLING ADDRESS �/ FACILITY NAME -Q �e CG DATE: 7/ SITE ADDRESS EMPLOYEE #: % t DATE: 2 Date Service Completed (if already completed): Street Number Dlrectian Street Name CItv Zip Code HOME or MAILING ADDRESS (If Different from Site Address) Payment Date /3 \ Street Number Street Name CITY STATEZIP ((( J�/� _ kN /(C1 SZ—\V PHONE #1 E%r. APN # LAND USE APPLICATION If PHONE#2 Exr. BOS DISTRICT LOCATION CODE ( Zoe( ) c�co — X015 CONTRACTOR / SERVICE REQUESTOR REQUESTOR ,, \ I1U (1.CHECK If BILLING ADDRESS VVV BUSINESS NAME � �p PHONE# C HOME or MAILING ADDRESS FAX# COMMENTS: CIN '` STATE ( n 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 performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, Standards, STATE and FEDERAL la �s//'/ ` APPLICANT'S SIGNATURE: ��,�U�t i'� DATE: 2 PROPERTY/ BUSINESS OWNER❑ OPERA766MANAGER❑ OTHER AUTHORIZED AGENT 11 IfAPPL/CANT is not the B/LLiNG 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 JOAQU N COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. PA TYPE OF SERVICE REQUESTED: TIM CWGK C COMMENTS: JO Ay 13 SgN2 y�GT 4�NH NMS ACCEPTED BY: Y EMPLOYEEM 'l+a DATE: 7/ ASSIGNED TO:C. EMPLOYEE #: % t DATE: 2 Date Service Completed (if already completed): SERVICE CODE: PIE: Fee Amount:S '�U Amount Pid c� Payment Date /3 Payment Type Cid IInvoice # Check # 2(0� Received By EHD 48-02-025 SR FORM (Golden Rod) REVISED 11/17/2003 7% iy