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SAN JOAQUIi WNTY ENVIRONMENTAL HEALT I?1'A1ZTMENT SERVICE REQUEST Type of Business or Property FACILITY ID # \ !,- SERVICE REQUEST # G .5VCCA-; o 1u y P NFl# EXT. �`� 4bl b33� S12c)o 3C, -�-) 8 OWNER/ OPERATOR CITY �o C �(—Vo rN ❑ EMPLOYEE #: C CHECK if BILLING ADDRESS FACILITY NAME G�3 EMPLOYEE #: SITE` SITE ADDRESS Date Service Completed (if already Completed: G ra r V t r, � (\ A SERVICE CODE: C �C�G C `� Fee Amount: �1� q S �-7b Street Number Direction Street Name Invoice # Cit Check It �gC� Zi Code HOME or MAILING ADDRESS (If Different from Site Address) Street Number Street Name CITY STATE ZIP PHONE #1 EXT. APN # LAND USE APPLICATION # EXT. 2f _ f�� )l -no ,;S `5 2 b '-- --7ON BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR ��Onb CHECK if BILLING ADDRESS \ !,- SSP BUSINESS NAME'1 � 2.V VC, o- dot^ 1r1 P NFl# EXT. �`� 4bl b33� HOME or MAILING ADDRESS ,5 FAx # ( &I'-) b3y2 CITY �o C �(—Vo rN STATE QC -k ZIP C'1' -BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or project specific ENVIRONMENTAL HF_ALTI I DE:PARTMI:N'r hourly charges associated with this project or- activity ractivity 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 COUN'T'Y Ordinance Codes, Standards, STATE and FEDERAL laws. APPLICANT'S SIGNATURE: DATE:: PROPER -FY/ BUSINESS OWNER ❑ OPERA -r00 MANAGER ❑ OTMnt AUTlimuzFD AGENT �� C, ly /f /1 PNlJCiI NT is lite 61l /,lNC P.IIlTY proof of rnttltorizntiotr to sign i.c required Title AU'ri-IOIZI%ATION 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 COUN'rY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available at the same time it is provided to me or my representative. TYPE OF SERVICE REQUESTED: 5�✓� �j 7 FZE (� COMMENTS: SSP �oUN� SPN �Oi> � ME iMEN� N APPROVED BY: ^O ` EMPLOYEE #: C DATE: > C ASSIGNED TO: EMPLOYEE #: DATE. Date Service Completed (if already Completed: SERVICE CODE: C P 1 E: 2� Fee Amount: �1� Amount Paid �-I Cj J -D Payment Date I D Payment Type ✓ Invoice # Check It �gC� Received By: EHD 48-01-025 REVISED 6-5-02 SERVICE REQUEST FOR4