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SAN JOAQUh, —OUNTY ENVIRONMENTAL HEALTH L—PARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID # SERVICE REQUEST # U A s srATLOO Asa b 5 5z!�;- OWNER /OPERATOR CITY &t/l "J E] moo- tux - CHECK If BILLING ADDRESS FACILITY NAME C �f�r UJ (� W.] Check # 2� b g Received By: SITE ADDRESS I�� /� {� II�� / ( / D. S�' (l e-1 C�`� -1 Stre t Numbed• Direction Street Name Cityi 2Ji Code HOME or MAILING ADDRESS (If Different from Site Address) Street Number Street Name CITY STATE zip PHONE #1 EXT. APN # LAND USE APPLICATION # (,Xq) g�7,0 `- b PHONE #Z EXT. ( ) BOS DISTRICTLOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR 4v moi` CHECK if BILLING ADDRESS BUSINESS NAME ASSIGNED TO: PHONE# ExT.Aa-c (4d 113 -- &1 0'3 � HOME or MAILING ADDRESS ( AU lJ I� �► Au -c- Date Service Completed (if already completed). FAX# (46T) W b -- & c CITY &t/l "J STATE e d zip Q1 /C ) BILLING ACKNOWLEDGEMENT: 1, 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. 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 COUNTY Ordinance Codes, Standards, STATE and FEDERAL laws. ) �j APPLICANT'S SIGNATURE: 1,q Qe,,i.t i, L) • �° � t.� .t.0 DATE: C 1 PROPERTY / BUSINESS OWNER❑ OPERATOR / MANAGER ❑ OTHER AUTHORIZED AGENT 0 ?e u l`t 41 M4,m ttroG -, -� If ADPL/CANT is not the BILLING PARTY, proof of authorization to sign is requir a= -e. AUTHORIZATION TO RELEASE ]INFORMATION: When applicable, I, the owner or =r0cated 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'T'Y ENVIRONMENTAL HEALTH DEPARTMENT as soon as it ispESaJ1e7nq@0Pjle same time it is provided to me or my representative. TYPE OFSERVICE R 5 REQUESTED: U1 1 h� �'f[C 1,'1 Jl COMMENTS: A � - coo&G-vii (�( FL YL�F1i� I ti du( -PS ACCEPTED BY: EMPLOYEE #:L / DATE: ASSIGNED TO: EMPLOYEE #: 2— DATE: Date Service Completed (if already completed). SERVICE CODE: P / E: Fee Amount: �� ° Amount Paid 3 1 Payment Date Payment Type ✓ Invoice # Check # 2� b g Received By: EHD 48-02-025 REVISED 11/17/2003 SR FORM (Golden Rod)