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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property CHECK If BILLING ADDRESS FACILITY ID # COMMENTS: SERVICE REQUEST # PHONE# EXT. �9 D HOME or MAILING ADDRESS cogs 1 �1-�— OWNER / OPERATOR ( ► C-140669. n T STATE ZIP �f �3 �,, CHECK If BILLING ADDRESS FACILITY NAME Uk, �c SITE ADDRESS `1 i, � Le DATE: /3 1 ASSIGNED TO: AG O 0 Street Number Direction 1 , Vv ' "Street City Zip Code HOME or MAILING ADDRESS (If Different from Site Address) Fee Amount: (� O g Amount Paid Street Number Payment Date Street Name CITY STATE ZIP PHONE #1 EXT. APN # LAND USE APPLICATION # q09) 610-I'd90 Invoice # Received By: PHONE #Z EXT. BOS DISTRICT LOCATION CODE (p03 ) 6 40 - 6-3 515 .529 CONTRACTOR / SERVICE REQUESTOR REQUESTOR CHECK If BILLING ADDRESS e5 D � 1/ COMMENTS: BUSINESS NAME PHONE# EXT. �9 D HOME or MAILING ADDRESS FAx # 10 sSO" vJ , k ' PoI412 ( ► CITY STATE ZIP �f �3 �,, 1 go t'� CA BILLING ACIICNOWLEDGEMENT: 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 ppl' ati and that th work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, Standard T E a FEDERAL wS. APPLICANT'S SIGNATURE: DATE: PROPERTY/ BUSINESS OWNERL�I OPERATOR / MANAGER OTIIER AUT11ORIZED AGENT ❑ If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required 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. w TYPE OF SERVICE REQUESTED: sp l S u ind I v , }rti }e La, di 1Slur ��YM COMMENTS: �V 13 20?. t Uk, �c ACCEPTED BY: I ` — EMPLOYEE #: DATE: /3 1 ASSIGNED TO: AG EMPLOYEE #: DATE: CI /S d✓:: Date Service Completed (if already completed): SERVICE CODE: S 3 PIE: Fee Amount: (� O g Amount Paid Payment Date 22 i Payment Type Invoice # Check # I OWZ Ift Received By: EHD 48-02-025 SR FORM (Golden Rod) REVISED 11/17/2003 rr D