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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property CHECK If BILLING ADDRESS FACILITY ID #SERVICE%REQUEST #G SV-UU 31 )Cr: CftAeN SY\oi HOME Or MAILING ADDRESSFAX# �2001 MciAeARl AI/C SSE 2 ACCEPTED BY: ! 1 OWNER / OPERATOR LI A STATE CZIP gS'3J D CHECK If BILLING ADDRESS 0G,A-TRAL V ( IA C, EMPLOYEE M DATE: Date Service Completed (if already completed): FACILITY NAME If I_ r SERVICE CODE: SITE ADDRESS I.O� `J' �p�QLa/I ICS (JT�-H(j0� `15330 Street Number Direction Invoice # Stree[Name CI ZI cotle HOME Or MAILING ADDRESS (If Different from Site Address) C2P2 R i t -7'1 9 O Street Number Street Name CITY �+ STATE � 3 p 2 O (,72(JCV- II C / PHONE #1 EXT. X91-32 1 APN # LAND USE APPLICATION # (ad9) PHONE #2 EXT. ( ) BOS DISTRICT LOCATION CODE CnNTR ACTOR / SERVICE REOUESTOR REQUESTOR /� ` CHECK If BILLING ADDRESS BUSINESS NAMEI, fZMAS COMMENTS: I , o tJ f \� PHONE # ExT. ao9 eq9-1-329 l HOME Or MAILING ADDRESSFAX# �2001 MciAeARl AI/C SSE 2 ACCEPTED BY: ( ) CIN O.J � LI A STATE CZIP gS'3J D 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. 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, StandardZ E/apa FEDERAL laws. —7 APPLICANT'S SIGNATURE: /�j DATE: IO/LI`/( l PROPERTY/ BUSINESS OWNER'I OPERATOR I MANAGER ❑ OTHER AUTHORIZED AGENT ❑ If APPLICANT 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, geotechnical data and/or environmental/site assessment information t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as Soon as It IS available and at the same time It Is 0"f1j. my representative IDen.... _1_Y' TYPE OF SERVICE REQUESTtED: COMMENTS: I , o tJ f \� 6 2OIf+7 � JOAQUIN COUNT ENVIRONMENTAL HEALTH DEPARTMEN ACCEPTED BY: EMPLOYEE M DATE: ASSIGNED TO: I EMPLOYEE M DATE: Date Service Completed (if already completed): SERVICE CODE: PIE: Fee Amount: Amount Pai /46-6, 00 Payment Date 1-7 Payment Type ( Invoice # I Check # 2� ecei ed By: EHD 48-02-025 SR FORM (Golden Rod) 07/17/08