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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID # SERVICE REQUEST # '540r o39gt2—I� OWNER I OPERATOR CHECK if BILLING ADDRESS J F. FACILITY NAME y J . i.�:t . S G�DCA EXT. SITE ADDRESS Sheet Number` Oimctlon RL'u'�, Street Name F-��po`r� CC Cit '2 2I Code HOME Or MAILING ADDRESS (If Different from Site Address) Street Numb¢r Street Name CITY STATE YIP PHONE#t ExT. I ) APN# fee Amount: LAND USE APPLICATION# PHONE #2 ExT. I 1 Payment Date BOS DISTRICT 11 LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQU ESTOR PAY MEN I 9X.114i 4 A -J GW VED CHECK If BILLING ADDRESS BUSINESS NAME,�D� ' C�KD.\1 S 6 aS. NOV t 1201t SAN JOAOUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT PHONE# zo EXT. HOMEor kILINGADDRESS O �5ot40i,3$ EMPLOYEE #: El V PAX# ASSIGNED TO: CITY STATE CIN zip C, S?J U'3 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. also certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN JOAOUIN COUNTY Ordinance Codes, Standards, STATE and FEDERAL APPLICANT'S SIGNATURE: "(� " K/ DATE: 1 � 1 17,'if PROPERTY/ BUSINESS OWNER ❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENTI If APPLICANT is nor the BILLING PARTY proof of authorization to sign is required Title 4 �1 AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, the owner or operator of the property located at the r 4 above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment;_ Information t0 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: QOoC LrP It PAY MEN I 9X.114i 4 A -J GW VED COMMENTS: NOV t 1201t SAN JOAOUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT ACCEPTED BY: V C -I EMPLOYEE #: El V DATE: / It ASSIGNED TO: � ��- EMPLOYEE#: 24a DATE: 1 1% / Date Service Completed (if already completed): SERVICE CODE: SZ - P1 E:�iO�y. fee Amount: Zgp, Amount Paid' Payment Date Payment Type GA W Invoice # Check # 6 I Received By: EHD 48-02-025 SR FORM (Golden Rod) REVISED 11/17/2003