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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property r1 O.J E.L L/�� C-4-zor— FACILITY ID # BUSINESS NAME — SERVICE REQUEST # PHONE# ExT. SEP 16 2009 W- 0c2S8 3 OWNER I OPERATOR HOME or MAILING ADDRESS^ ! i (� n �() 7 Y`QJ CHECK If BILLING ADDRESS FACILITY NAME S4 ti 3 4 CITYSTATE 4.� /I -S90 C - V\ SITE ADDRESS loco �x`�'"-Y s�""'-- DATE: Gr 1(4 / 0 ASSIGNED TO: P>Ea "Zfr QS=-�"� EMPLOYEEM (o 2_(3 DATE: q /(P 1v Date Service Completed (if already completed): SERVICE CODE: IS --Z Z Street Number Direction Street Name Amount Paid 1 ag3-0D -0 i Zip Code HOME or MAILING ADDRESS (If Different from Site Address) Invoice # Check # 33 S-3 J I Received By: Street Number Street Name CITY STATE ZIP PHONE#1 ExT• APN# LAND USE APPLICATION# PHONE#2 ExT. BOS DISTRICT LOCATION CODE ( ) 5 3 CONTRACTOR / SERVICE REQUESTOR REQUESTOR r1 O.J E.L L/�� C-4-zor— CHECK if BILLING ADDRESS 10 BUSINESS NAME — PHONE# ExT. SEP 16 2009 HOME or MAILING ADDRESS^ ! i (� n �() 7 Y`QJ DOHEALTH FAx# (20') S4 ti 3 4 CITYSTATE 4.� ZIP S 3 V\ 11 I f EMPLOYEE #: D J? Z 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 laws. APPLICANT'S SIGNATURE:— � DATE: Cf-lL - oa PROPERTY / BUSINESS OWNER ❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT C ,pyr �cc<.IPj^ If APPLICANT is not the BLLLLNG 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 JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is provided to Ine or my representative. {FOO(-/S'd 4 TYPE OF SERVICE REQUESTED: �Qy} 1 ✓L. r1 O.J E.L L/�� C-4-zor— PAYMENT COMMENTS: SEP 16 2009 SAN JOAQUIN COUNTY ENVIRONMENTAL DOHEALTH � FF 64 DEPARTMENT 3 ACCEPTED BY: C) C_L vieE 11 I f EMPLOYEE #: D J? Z DATE: Gr 1(4 / 0 ASSIGNED TO: P>Ea "Zfr EMPLOYEEM (o 2_(3 DATE: q /(P 1v Date Service Completed (if already completed): SERVICE CODE: IS --Z Z PIE: -3 & (9 Z Fee Amount: -4 23o , Amount Paid 1 ag3-0D -0 Payment Date -C l b(07 Payment Type Invoice # Check # 33 S-3 J I Received By: EHD 48-02-025 SR FORM (Golden Rod) REVISED 11/17/2003