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SAN JOAQ, COUNTY ENVIRONMENTAL HEAL? IEPARTMENT SERVICE REQUEST Type of Business or Property CHECK if BILLING ADDRESS BUSINESS NAME I `- o ^ y—(V i FACILITY ID # o S,<oERVICE REQUEST # F9�/6N 13fS / Cl il�000��C) Z Date Service Compleled (if already completed): SR©9/9q OWNER / OPERATOR Fee Amount: '"Z C> 1- Amount Pal nz-, Payment Date Payment Type ✓ Invoice# Check# 35/y Received By CHECK If BILLING ADDRESS FACILITY NAME rj /1 j Lr� ,W �r l j J * j, e '� SITE ADDRESS Street Number Directlon Street Name Cit HOME or MAILING ADDRESS (If Different from Site Address)ECEIVE Street Number Street NIMi CITY STATE ZIP 014 Sq PHONE #t Ems. APPN # LAND USE APPLICATION # „�EL HDC AR ALN EP AlEhir PHONE#2 Ex. SOS DISTRICT LOCATIgQNCODE ( 1 D • �O(f,�1 CONTRACTOR / SERVICE REQUESTOR REQUESTOR CHECK if BILLING ADDRESS BUSINESS NAME I `- o ^ y—(V i g o Ho M r MAILING ADDR F9�/6N 13fS / Cl ZIP q.5fi�� ■I 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 lication and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, StandarS /yjE and FE RAL laws. G/ APPLICANT'S SIGNATURE: OpL DATE: �w,///Y-�X PROPERTY/ BUSINESS OWNER❑ CIrRATOR/MANAGER ❑ OTHER AUTHORIZED AGENT,Avy � ��A If APPLICANT is not the BILLING PARTY proof of irorization to sign is require/d 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 COUNTY 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: COMMENTS: �I-eplaz&, S�0 ('U d(2alA-)� �a�� P�sarWairtl,�QW ery"" ACCEPTED BY: ^�� ` ( {�,.�-, r e,�` EMPLOYEE M /. % DATE: 3 7 / ASSIGNED TO: 5+ ` EMPLOYEE #: 1 O DATE: Date Service Compleled (if already completed): SERVICE CODE: ZZ PIE: 360Z - Fee Amount: '"Z C> 1- Amount Pal nz-, Payment Date Payment Type ✓ Invoice# Check# 35/y Received By EHD 48-02-025 SR FORM (Golden Rod) REVISED 11/17/2003