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SAN JOA( _ _N COUNTY ENviRONMENTAL HEALOEPARTMENT SERVICE REQUEST . Type Bu iness or Property BUSINESS NAME FACILITY ID # SERVICE REQUEST # OWNER / OPERATOR (1r,,,1�^ v JI CITY STATE ZIP CHECK If BILLING ADDRESS FACILITY NAME 111 J THEA7ti�AFy IA ' SREAIoDRESS `I Street Number N Direction O' �^ "I I "Street Name EMPLOYEE #: 2 1. 7 O w Git ZI Coda HOME or MA ING ADDRESS (If Different from Site Address)Mott Srtre�nee� Number V I l VL r�WS lre�elt�Name'Ul1 CITY nL�,�A u�,tn1 SERVICE CODE;1, 0 �� STATE C zip q�/�' ) wI'/ PHONE#1 (w)W1-ggqq EXT. APN# 13s - spy - r3 LAND USE APPLICATION # PHONE#2 ( ) ExT. Check # /68 I Recei d By: BOS DISTRICT 00 r LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR o1, 1„^ 1� t�\�I� CHECK If BILLING AOORE55 BUSINESS NAME PHONE# Exr. HOME Or MAILING ADDRESS FAx # CITY 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 a lication and that the work to be performed will be done in accordance with all SAN JOAQUIa COUNTY Ordinance Codes, Stant�ards�, TAt TE and FEDERAL laws. APPLICANT'S SIGNAT`UR/EEl� ,k&.' DATE: Ll r 1 I PROPERTY/ BUSINEss OWNER`�JL) OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT 13 IfAPPLIC:AN isnotthe B7LL%NGPAR%Y 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 t0 me or my representative. TYPE OF SERVICE REQUESTED:!''/ CG�I�gL C�z�. "\ ME COMMENTS: VSD 29 SAN 2013 0 E AQUIt THEA7ti�AFy IA ' ACCEPTED BY: EMPLOYEE #: 2 1. 7 O DATE: / ASSIGNED TO: EMPLOYEE At: '7 / I DATE: Date Service Completed (if already completed): SERVICE CODE;1, 0 �� P) E� 1662 - Fee Amount: tl z --� Amount Pai as4a Payment Date 6 -7113 Payment Type Invoice # Check # /68 I Recei d By: EHD 48-02-025 SR FORM (Golden Rod) REVISED 11/17/2003