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SAN JOAQUIN —OUNTY ENVIRONMENTAL HEALTH SARTMENT SERVICE REQUEST Type of Business or Property CHECK If BILLING ADDRESS FACILITY ID # SERVICE REQUEST # /�1ar�ila HOME or MAILING ADDRESS ZSG%S Rat /road Ova. COMMENTS: OWNER i OPERATOR STATE Cjq ZIP 53c n 77i& � SIJ � U i- � llQ &`� / I lai-!\ U CHECK If BILLING ADDRESS FACILITY NAME l 11 Q t /, rf SITE ADDRESS / /'y? APPROVED BY: /' 1CI�'�ba1'%GC{rt�,-� EMPLOYEE #: V01 Street Number Direction Street Name DATE: Cit Zip Code HOME or MAILING ADDRESS (If Different from Site Address) P t E: Fee Amount:Amount Paid Street Number Payment 6ate 7 p 7 Street Name CITY STATE Zip PHONE #1 EXT. APN # LAND USE APPLICATION # PHONE #2 EXT. BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR /r ( `I j� CHECK If BILLING ADDRESS BUSINESS NAME 17. n1r m TYPE OF SERVICE REQUESTED: PHONE EXT. Z HOME or MAILING ADDRESS ZSG%S Rat /road Ova. COMMENTS: FAX# (OC)9) 3?- 3111F CITY ��, �� C STATE Cjq ZIP 53c n BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or project specific ENVIRONMENTAL HEALTI-i 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 1 have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, .Standards, SLATE and FEDERAL, laws. APPLICANT'S SIGNATURE: _ DA•rE.:�,�� PROPF.R'rl' / BUSINESS OWNER OPERATOR /MANAGER ElOTIIER AUTHORIZED AGEN72//�'1�)�°ogl f7 eA11)14011y if APPLICANT is not the BILLING PARTY, proof of authorization to sign is required Title AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, 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. PAYMENT EHD 48-01-025 SERVICE REQUEST FORM REVISED 6-5-02 RECEIVED TYPE OF SERVICE REQUESTED: COMMENTS: J U L 2 2004 SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT APPROVED BY: EMPLOYEE #: V01 DATE: /7 ASSIGNED TO: yn co EMPLOYEE #: DATE: Date Service Completed (if already completed): SERVICE CODE: P t E: Fee Amount:Amount Paid '�r L l /.00 1 Payment 6ate 7 p 7 Payment Type Invoice # Check # l � Received By: -Zl� EHD 48-01-025 SERVICE REQUEST FORM REVISED 6-5-02