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SAN JOAQ+COUNTY ENVIRONMENTAL HEAL*EPARTMENT SERVICE REQUEST Type of Business or Property CHECK if BILLING ADDRESS FACILITY ID # SERVICE REQUEST # PHONE# Exr. W OWNER / OPERATOR K (V 1" 0\3\V-GOO CHECK If BILLING ADDRESS FACILITYNAME zip g ENVIRONIViEWV HEALTH// SITEADDRESS EMPLOYEE#: 3' 3 3 Seeet Number \\ 'U��/� fJ .{/� / J� Cl- ��" �-IC A-,;,1 DlrGellon HOME or MAILING ADDRESS (If Different from Site Address) /V Sheol Namc Cit ZI Codc '3[—IF1 10 DATE: M q_ Date Service Completed (if already completed): CIN SERVICE CODE: (9 A Stroel Number Siroet Nanm Fee Amount: 2.;? -G — I Amount STATE Zip PHONE #1 (ZcP, ) —7Ci ^ _ 3 z I 5 EXT. APN # Payment Type LANG USE APPLICATION # PHONE#2 ( i Exr. 0 1 Received By: N cr- SOS DISTRICT LOCATION CODE CONTRACTOR/ SERVICE REQUEST"') REQUESTO jj D-/�/j((/GL �2.y-jZ CHECK if BILLING ADDRESS BUSINESS NAME PHONE# Exr. HOME Or MAILING ADDRESS FAX# K (V 1" 0\3\V-GOO CITY (�( on t rain STATE I /�� !/' zip g —U �..ItI1.vrvL,cM,LIVLLN 1: 1, the undersigned property or business owner, operalnr or authorized agent of Same, acknowledge that all Site and/or project SpcC11ID ENVIRONMENTAL Hf- 'ALTH DEPARTMENT hourly charges associated with tills projcct or activity will be billed to ole or my business as identified oil this forul. I also certify that I have prepared this application and that the work to be performed will be clone in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, S/andards, STATE and PI?DERAL laws, APPLICANT'S SIGNATURE: /� �� DATE:_ � fl �I) (Of PROPERTY/ BUSINESS OWNER 11 OPERATOR /IVIANAGi'N ❑ OTHER AUTHOnt'/,lfn Ac4:Mr'�" 1/'ArrLlc,im-is not rile UUJJNC PART)', proofof authoriuuinn to sign is required Tirte AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located Eli the above site address, hereby authorize the release of any and all results, g otechnical data and/or environmental/site asscsslllcnl information 10 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEAum DE4\RTIMI-NT as soon as it is available and at the stone Little it is provided to ole or Illy representative. TYPE OF SERVICE REQUESTED: _, ,•\ �Vi1� ,��j COMMENTS: _A V K (V 1" 0\3\V-GOO apt? ; : 61316 SoA JO VoW PjMECS oNZNOEPP ENVIRONIViEWV HEALTH// ACCEPTED BY: EMPLOYEE#: _ DATE: L I ASSIGNED TO: EMPLOYEE #: '3[—IF1 10 DATE: M q_ Date Service Completed (if already completed): SERVICE CODE: (9 A p i E: 23 o g Fee Amount: 2.;? -G — I Amount Paid Z �f — Payment Date `I 1 Ab Payment Type Invoice # Check # 0 1 Received By: N cr- EHD 48-02-025 REVISED 11/17/2003 SR FORM (Golden Rod)