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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID;� SERVICE REQUEST# FA UU 7qz)' --;CDC72-0-70 OWNER/OPERATOR — — CHECK If BILLING ADDRESS FACILITY NAME ff SITE ADDRESS 77 '�// 5 � !�4�j �S � /3 lJ Street Number Direction 13 V�t�� Street Name city .'io Code _ HOME or MALI-ING ADDRESS (If Different from Site Address) tatrisr- I Street Number Street Name CITY STATE ZIP PHONE#1 EXT. APN# LAND USE APPLICATION# (2&7) qq3 PHONE#2 EXT. BOS DISTRICT =1 LOCATION CODE ( ) CONTRACTOR SRy L sESLT R REQUESTOR Q C' CHECK If BILLING ADDRESS BUSINESS NAME PHONE# EXT. - a HOME or MAILING ADDRE S FAX# ray ,,.a.,l b vd / (1 s - d z Z o CITY 15P6VC,&- STATE G6- ZIP 15'7,O-p- 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 th ork to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, Standa(q-s�.5 TE and FEDE L laws. APPLICANT'S SIGNATURE: DATE: C� / PROPERTY/BUSINESS OWNER❑ OPERATOR/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 provided to me or my representative. TYPE OF SERVICE REQUESTED: ' )n C MENTS: f ' (hit / SAN JOAQUIN COUNTY c / ENVIFtOPATAL ey 1" .f".JT (�� / HEALTH [)[PARTiUIENT ACCEPTED BY: ) r EMPLOYEE#: DATE: j I ASSIGNED TO: ��/��/ ��, EMPLOYEE#: DATE: lam" /& Date Service Completed (if already completed): SERVICE CODE: , P/E ,�� Fee Amount: Amount Paid 13 C), CJ (-, Payment Date �faI Payment Type Invoice# +" Received By: �. EHD 48-02 025 / �, �� S� 1„ j , L � SR FORM(Golden^FFt d T EI) 07/17/08 �U alt l� AUG 21 206 SAN JOAQUIN COUNTY u• ENVIF70MpA1-rA.