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+ SAN JOAQU ,OUNTY ENVIRO- NMEN.TAL HEALTL .'ARTMENT SERVICE REQUEST Type of Business or Property ` C� J�� l/�/ FACILITY ID # CHECK If BILLING ADDRESS El SERVICE REQUEST # `Z E--A,-i L C, ars 0 LL"At— PHONE # 9 16 ExT• 3 4-3 - I (s 2 - HOME or MAILING ADDRESS HOME �.0. F30y- rozr OWNER / OPERATOR FAX # (qty) If BILLING ADDRESS — F, C E v C' ^ C - SAN JOAOUIN COUNN CHECK FACILITY NAME _ F, L �v C Q C -I IRONMENTAL ACCEPTED BY: SITE ADDRESS , 1 t ►,( T . KA P, w F— C - Cl S 3 3 (o � -` 1 Street Number Direct Street Name Ci Zi Code HOME or MAILING ADDRESS (If Different from Site Address) I Payme t Date14 Payment Type SA rv, E Street Number Street Name CITY Receiv d By:,�� STATE ZIP PHONE #1T• APN # LAND USE APPLICATION # PHONE #2 EXT. ( ) BOS DISTRICT LOCATION ODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR ` C� J�� l/�/ CHECK If BILLING ADDRESS El BUSINESS NAME L! a� C _ n �t�2c PHONE # 9 16 ExT• 3 4-3 - I (s 2 - HOME or MAILING ADDRESS HOME �.0. F30y- rozr FAX # (qty) 3�-3-<« z - CITY W/ SAN JOAOUIN COUNN STATE C A ZIP 9 S/ Ct 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 a d that the work to b performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, Standards, TA �d EDERAL laws. APPLICANT'S SIGNATURE: I DATE: 'Z- PROPERTY/BUSINESS OWNER OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT MJ Q►�R 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 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: C A rE Z E V C F.ivJ i?-t'7—r O .4 COMMENTS: RFCFi:r 11200 r� �� SAN JOAOUIN COUNN IRONMENTAL ACCEPTED BY: �1 EMPLOYEE M 1�h D _ DATE"AL1 ASSIGNED TO: Ad 12 U EMPLOYEE #: DATE: Date Service Completed (if already completed): SERVICE CODE: P 1 E: Fee Amount:2 J0 it Amount Paid l �(_) I Payme t Date14 Payment Type Invoice # Check # 3 Receiv d By:,�� EHD 48-02-025 REVISED 11/17/2003 SR FORM (Golden Rod) ' ✓ �,f. v� �.( V r,� evil