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i SAN.JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID# SERVICE REQUEST# G 4vrC4 � OWNER I OPERATOR S% CHECK if BILLING ADDRESS FACILITY NAME I ' SITE ADDRESS� S SStreet Number Dir.ection r t5 rest Name Cit Zip Code HOME orMAILING ADDRESS (If Different from Site Address) �] / /7IV-5 Street Number V Street Name CITY STATE ZIP '-7 ef 5-3 7 PHONE#1 EXT, APN# LAND USE APPLICATION# PHONE#� ExT BOS DISTRICT LOCATI9{J E { ) 4 GCy CONTRACTOR/ SERVICE REQUESTOR REQUESTOR r'fin, /J S L[ �1 /Z ve 1"R `/1 4 -PQ r /rellX �/ele.7^v a 7 C14ECK if BILLING ADDRESS BUSINESS NAME 1 QGt �'1 PHONE# EXT. Ws yto&—ZW HOME Or MAII-94raADDRE S FAX# CITY P1 ore ^70 STATE ZIP '�P,5 35+ BILLING ACKNOWLEDGEMENT: 1, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or project specific ENVIRONMENTAL HEALTui 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, STATE and FEDERAL laws. APPLICANT'S SIGNATURE: DATE:_ 9�3 /e;7 1 PROPERTY/BUSIIYE.SS OWNER❑ OPERATOR/NIANAGFR OTHER AUTHORIZED AGFNPQ d se/ ` 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 ENVIRONMENTAi.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: ''AI> 1 7-"`70C— (—p 4-/J - J 6-- COMMENTS: 1oa RECEIVED SEP -3 2049 SAN JOAQUIN COUNTY ENVIRONMENTAL HFAI-TH DEPARTMENT I ACCEPTED BY: I()FIG D,Q EMPLOYEE#: /Yt Z/ DATE: C? 3 ASSIGNED TO: 1 0'i ID t�-C—os EMPLOYEE#: L4�o /(� UATE: Q 3 O Date Service Completed if already completed): `C G P ( Y P J� SERVICE CODE: S 2S P i E' �CoO Z Fee Amount: ,j 7 D D Amount Paid S b Payment Date 3 !!! Payment Type ✓ invoice# Check# !J-`S Received By: EHD 48-02-025 REVISED 11/17/2003 SR FORM(Golden Rod)