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SAN JOAQL COUNTY ENVIRONMENTAL HEALT. JEPARTMENT SERVICE REQUEST Type of BUsi ess or roperty �ra�K CHECK If BILLING ADDRESS FACILITY ID # r�� COMMENTS: ` , t 5 vcT,a 4 CoWi.S SERVICE REQUEST # o66�, � Z OWNER I OFER�TOR O ACCEPTED BY: CHECK If BILLING ADDRESS FACILITY NAME 1 SrrE ADDRE Street Number Direction %\ r , ar.,2 'J� c� b S .1 Name DATE: CI Zi Cotle HOME or MAILING ADDRESS (If Different from Site Address) Street Number SERVICE CODE: 55 ? Street Name CITY Amount PaidZ�25v , (,� STATE ZIP PHONE#1 E". ( ) Payment Type I/ APN # LAND USE APPLICATION # PHONE #2 Ex . ( ) Received By: BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR f N1 r C �,^„^� CHECK If BILLING ADDRESS 1 - BUSINESS NAME V �C �Xey\� \ s'' `'J COMMENTS: ` , t 5 vcT,a 4 CoWi.S PH�� ONE# Ezi. J HOME Or MAILING ADjDDRESS � C7 � � � ACCEPTED BY: FAX # Ilio CITY y STATE LA ZIP C) 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 applicat' n an at the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, Standards, ST and ERRAL laws. APPLICANT'S SIGNATURE: DATE: PROPERTY/ BUSINESS OWNER❑ OP RATOR/ AGER ❑ OTHERAUTHORIZEDAGENTIZ 5- If APPLICANT is not the ILLIVGPAR Tr proof of authorization to sign is required JT111 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 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: O"Lp0v:� 1tL_�Iytic COMMENTS: ` , t 5 vcT,a 4 CoWi.S W tl C� 1, 'l � \-G•._sr\ TJ FEBAYME F E 01 SAN JOAaUIN ENVIROM HEALTH Dt-tl ACCEPTED BY: EMPLOYEE #: DATE: ASSIGNED TO: EMPLOYEE M DATE: Date Service Completed (if already completed): SERVICE CODE: 55 ? P �.Z�' Fee Amount: "+ Amount PaidZ�25v , (,� Payment Date '7 (f 3 Payment Type I/ Invoice # Check # D (,2_,o g b Received By: EHD 48-02-025 SR FORM (Golden Rod) REVISED 11/17/2003 NT ED 2013 COUNTY NTAL ,RIMENT