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SAN JOAQUI'- 'AUNTY ENVIRONMENTAL HEAL7 7EPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID# SERVICE REQUEST# S I kVL.C, J.� I,lL OWNER/OPERATOR DA q A r CHECK If BILLING ADDRESS FACILITY NAME .Y "Mc-r- 6s i S A ESS w . M•f/N HC R L q l,J( 9j.�Df` w 70Av ,tL� VTOCV reu gSzD-7 J Slreet Number Direction Street Name cityZiI,Code HOME or MAILING ADDRESS (If Different from Site Address) R-JCS 1 LI✓IDUD Py- 103%e 7lt-.103 Street Number Street Name CITY STATE ZIP 510afc-a JJ Cit ' '2 7 PHONE#i ET. APN# LAND USE APPLICATION# (2." 1 9SL — 'sb62. 313 077,&fgo, L1,O-7'7,NTo-e PHONE#2 En. BOS DISTRICT LOCATION DE (zoq) Lrlo - '3"72t- CONTRACTOR / SERVICE REQUESTOR REQUESTO'RN I14�NNI /tivs CHECK If BILLING ADDRESS BUSINESS NAME J PHONE# Ems' .41JUZA- S S.f Co fJsur n'J& CI t/t C IJ 11J"x— 2 8 a 3 1.f f HOME Or MAILING ADDRW FAX# Ilam Ik S-r 2a9- ?tl$ CITY dv STATE cot ZIP qs3 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 Codes,Standards, STATE and FEDERAL laws. APPLICANT'S SIGNATURE: AMC"( /c Uv DATE: '7 —-5 / PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER OTHER AUTHORIZED AGENT IfAPPLlCANTisnottheBiimNGPAR 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 environmentallsite 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: SLk, ,DACE $'u r_S'Lt G, CO✓ , l - ,gCAV12-?— COMMENTS: 1� Y y3`J PAYMENT RECEIVED APR 52004 SAN JOAQUIN COUNTY ACCEPTED BY: v L-4 LE EMPLOYEE#: Q 3.Z-MEALTH DE ER Z-4 U ASSIGNED TO: 6 D� -,:; I EMPLOYEE#: ©/ -t- DATE: 4 S O Date Service Completed (if already completed): SERVICE CODE: 3/.5 PIE: _2 C,- 03 Fee Amount: I C(o,Q J Amount Paid Payment Date Payment Type Invoice# Check# Received By: EHD 48-02-025 SR FORM(Golden Rod) REVISED 11/17/2003