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SAN JOA4! _,q COUNTY ENVIRONMENTAL HF,AL'.11i DEPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID # SERVICE REQUEST # Kintner al �[ ✓ / RUSH _ L �I �1 z aWWP 0OPERATOR DATE: ebb t b1- ASSIGNED TO: &` -&% EMPLOYEE #: _5(, •2't— DATE: e / 7,F- 0 (- CHECK If BILLING ADDRESS® FACRaY NAME 67 n i ,,SITE SOVICECODE: Ci3 PIE: '��p ADDRESS � ✓ men a ra. V o' r-��"53 7 (P Number txv.a n street Name Zip CodeStreet HOME Or MAILING ADDRESS (if Different from Site Address) i 1 Street Number .� rt et Neme T CITY' .. V� J I " STATE ZIP IF, PHONE#t Ear. IAA 1-14- APN # Z48I! Qzi-I LAND USE APPLICATION PHONE #2 EXT. BOS DISTRICT LOCA ODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR kNnui;CHECK1f BILUNe ADDRESS® BUSINESS NAME /I tt - PHONE# EXT. ca t I JJ c F�IOC� LLC T N -It)—'k- EXT. HOME Or MAILING ADDRESS _ --- Ty F # .-� _ 111 n. 006ef 1� ;e Fix (Y)w) s!N- a8t8 CITY I le• 11 ,.l—r,,%TATE 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 DEPARI'MENT hourly charges associated with this project or activity will be billed to me or my business as identified on this forth. I also certify [hat I have prepared this appy' tion and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, Standards, and FEDERAL, laws. / GZ APPLICANT'S SIGNATURE: I DATE:j� PROPERTY/BUswms OWNER 19 OPERATOR/hfANAGER❑ O'FHERAUTHORIZEDAGENT )w& If APPLICANT is not the Bull; P.4R 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 HEAL'T'H DEPAR'rMENT as soon as it is available and at the same time it is provided to me or my representative. TYPE OF SERVICE REQUESTED: COMMENTS: RUSE' �[ ✓ / RUSH ACCEPTED BY: V EMPLOYEE #: C113 _ DATE: ebb t b1- ASSIGNED TO: &` -&% EMPLOYEE #: _5(, •2't— DATE: e / 7,F- 0 (- Date Service Completed (if atrea y completed): SOVICECODE: Ci3 PIE: '��p Fee Amount:4 r-5,DLI Amount Paid �5, G -7J Payment ate gj r(j� Payment TypeL i- IE, .cam Invoice # Check # & 313 Received By: � EHD 48-02-025 SR FORM (Golden Rod) REVISED 11/17/2003