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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID# SERVICE REQUEST# AGFI(o'�-7,jRAL. AP11; SR00 313`X4- OW NER I OPERATOR _ TOz L. DUTTiA J. D, rtNANctAL) CHECK if BILLING ADDRESS FACILITY NAME SITE ADDRESS 29 SOTE GROOMS V en^b oAkkDAI� 95'-��i Sheet Number Direction Street Name city Zip Code HOME or MAILING ADDRESS (If Different from Site Address) S-TAANDI'a=oRfj AV E N aLDF,C ) 1566 A D AY$ .'8L (.Street Number Street Name Cm I�nAESToSTATE ZIP C ALI Ftsy2N i A PHONE#1 Exr. APN# LANDUSSE APPLICATION# ' PHONE#2 En. BOS (STRICT LOCATION CODE ( ) CONTRACTOR/ SERVICE REQUESTOR REQUESTOR �AI��R '_. Ll)I2T15 CHECK If BILLING ADDRESS BUSINESS NAME CIVIL �.tJGlhl£ti12.. PHONE# E�• 2M 3G8-416 HOME or MAILING ADDRESS FAx# 4 w LAzA ( ) CITY L.. STATE GA ZIP 95 <D BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator o authorized agent of same, acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associat 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. APPLICANT'S SIGNATURE: �c# 1cL J DATE: 093D�p2 PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT® GIVIL �NGIh11=�72 IfAPPLICANTIs 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 environmentaUsite 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. I1 TYPE OF SERVICE REQUESTED: RiFX,EW f oMy {Z6Fl�-'r S(Ar aCC t} S(-yb (' ACd ; ingt'M COMMENTS:. . APPROVED BY: II ' , O EMPLOYEE#: �y'7/ DATE: L1 —30 _ O-L ASSIGNED TO: UNY ISH m�� EMPLOYEE#: e-L1-�- r 54 DATE: ,3 O -O ti Date Service Completed (I?already completed): SERVICE CODE: '315 PIE: 6 0 3 Fee Amount: l l Amount Paid - Payment Date Payment Type Invoice# Check# Received By: EHD 48-01-025 SERVICE REQUEST FORM REVISED 65-02