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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID # �o SERVICE REQUEST # OWNER /OPERATOR Atm �� "" ///�� ,��,...,,, _ I\ /ter l N �a iqp e— < � N c. 1K1 CHECK If BILLING ADDRESS El.- FACILITY NAME A LeI J E M �I I I/�.7 i FAX# SITE ADDRESS 28,50 Street Number I Direction . Cf}e-1FD1'N/A Street Name �/. p JVC.k'%D� I City /� _/sZLoq Zip Code HOME or MAILING ADDRESS (If Different from Site Address) 3 Z Street Number �) L 57--C D W AY Street Name I CITY S(J71 -0 STATE ZIP CACISSa 3ti PHONE #1 E-- (�)O 2 -Lf 3 - 19 G APN # Date Service Completed (if already completed: LAND USE APPLICATION # PHONE#2 Ems. P / E: -2— Fee Fee Amount: BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR R,,}^K� •/r 1 L'� �ff' CHECK If BILLINGADDRE55 BUSINESS NAME ALPINL /v�rr}2I«T PHONE# E'R. '2 Ll3-51,016 HOME or MAILING ADDRESS 21 ✓''y�(OAy/( G FAX# CITY STATE Zip ,-y� 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. 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 Coder, Standards, STATE and FEDERA laws. 1 APPLICANT'S SIGNATURE- DATE: I Z I 12O PROPERTY/BUSINESS OWNER❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT/ hRES I �t- NT If APPLICANT is not the BILLING PARTY proof of authorization to sign is require(l 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 to 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: S(A On RECEIVED COMMENTS: ✓''y�(OAy/( G Si1jp V DEC 0 9 1020 SANIARON N COUNTY ENVIRONMENTAL HEALTH DEPARTMENT ACCEPTED BY: I n Irk W, 'I EMPLOYEE #: /) v DATE: I v/ 2-0 ASSIGNED TO: ^ II .p ' EMPLOYEE #: DATE:ql 12-0 1o Date Service Completed (if already completed: SERVICE CODE: 0(/ ! P / E: -2— Fee Fee Amount: Amount Paid I 2 .00 Payment Date 12-1% 2 Payment Type V, I Invoice # Check ,fl 7 3 of 5; Received By: EHD 48-02-025 REVISED 11/17/2003 ?g01V01;-ag SR FORM (Golden Rod)