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SAN JOAQU 7,0UNTY ENVIRONMENTAL HEALT" EPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID # MOO co 71/ SERVICE CHECK if iee)obsp-jL BILLING REQUEST # ADDRESS OWNER! OPERATOR FACILITY NAME , . - r/ FFAmy Ss-tale f ( a-S-0 e 2 ./ tOeer SITE ADDRESS 9C)9 Street Number Direction Tr ?TAN/ Street Name C--: (2-- Fip ocrJ Cltv Zip Code HOME or MAILING ADDRESS (If Different from Site Address) Street Number Street Name CITY STATE ZIP PHONE #1 Eat APN # LAND USE APPLICATION # PHONE #2 EXT. I ( ) BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR, t r-, c>lcrcvNi )144-6•LA Do CHECK if BILLING ADDRESZ- A BUSINESS NAME L.. JS40 Irs, e cia Li 1- P-B/VIO GU Ai PHONE # ( 30 1 ) fl?- C.roo HOME or MAILING ADDRESS, .6700 Di al-S;41{A 9-A FAX # ( ) s3)'- &SF, CITY Cev,es CA. 7.c3o 7 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 performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, Standards. St AT / and FEDE laws. APPLICANT'S SIGNATURE: ( 4110 / DATE: 10 7.09 /42. PROPERTY / BUSINESS OWNER 0 OPERATOR / MANAGER 0 OTHER AUTHORIZED AGENT 0 If APPLICAIV7' 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, geotechtticaAcWird/WhntimFtpl/site assessment information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as as a iS avai "b1 alits at It same time it is provided to me or my representative. TYPE OF SERVICE REQUESTED: 17 n --(- -via. 13 PAYMENT. COMMENTS: RECEIVED ' our 2 4 202 , SAN JOAQUIN COWRY ENVIRoNmENTAL HEALTH DEPARTMENT ACCEPTED BY: C_ giy Ai EMPLOYEE #: DATE: ASSIGNED TO: ?er, Mr 2.4_ EMPLOYEE #: DATE: Date Service Completed (if already completed): SERVICE CODE: 3/1.....--- PIE: 2-- Mb Fee Amount: j .2,S- C I , Amount Paid 4672 Payment Date Payment Type I Invoice # Check # A6-ye (0/7 Received By:e1) SR FORM (Golden Rod) EHD 48-02-025 REVISED 11/17/2003