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SAN JOAQU OUNTY ENVIRONMENTAL HEAL'DEPARTMENT w SERVICE REQUEST 1 Type of Business or Property FACILITY ID# SERVICE REQUEST# OWNER I OPERATOR C,r" CA CHECKifBILLING ADDRESSE FACILITY NAME Cay eA4-tr- co ar. SITE ADDRESS n`<ddS L&4 h r O J533 6 �-4r1an Street Number Direction Street Name city Zle Code HOME Or MAILING ADDRESS (if Different from Site Address) Streel Number Street Name CITY STATE zip PHONE#I EXT, APN# LAND USE APPLICATION# PHONE#2 EXT. BOS DISTRICT LOCATION COBE CONTRACTOR / SERVICE REQUESTOR REQUESTOR �y t �} UOA4�S (fo EhV k' 1-U+�1^^eV 1 CHECK if BILLING ADDRESS r; BUSINESS NAME PHONE# EXT' a c - r ori HOME or MAILING ADDRESS o l4 (aG�t ) 4/b7- CITY S� oX STATE CA- zip q,5-a (.s- BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or project specific ENVIRONMENTALHEALTii DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as identified on this form. i I also certify that I have prepared this appli tion and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Caddo',Standart/ nd FEDERAL laws. APPLICANT'S SIGNATURE: DATE: PROI-FRTY/RtISINFSSOWNER❑ OI'FRATOIZIMANACER ❑ OTIIFRAUTHORIZEDAGFNTW' ACq,-* P /�r ' `C' -�: 1 If APPLICANT 'not the BILLING PARTY,proof of authorization to sign is required Title AUTHORIZATION TO REI,EASE 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 HEALT}t DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. PAYMENT TYPE OF SERVICE REQUESTED: fJ 4= FR qAAA COMhM1ENTS: ` ' / �� j� APR Z %3 MUJ � SAN It4 COUNTY PUBLICO HEQAItTH SERVICES ENVIRONMENTAL HEALTH 9MSI0N APPROVED BY: EMPLOYEE; : C TATE: ASSIGNED iO: , �J EMPLOYEE#: DATE: 1 F Date Service Completed if already completed): SERVICE CODE: 3 P/E: �3d Fee Amount: Amount Paid A-2-6-7 Payment Date i Payment Type ✓ invoice# Check# 30 7 Received By: EHD 48-01-025 SERVICE REOUIEST FORM REVISED 6-5-02 w . .