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SAN JOAQUIr.OUNTY ENVIRONMENTAL HEALT,_.,)EPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID# SERVICE REQUEST# RES/DENT/AL OWNER I OPERATOR CHECK If BILLING ADDRESS MR . P.4R tvDE2 c c0�! FACILITY NAME SITE ADDRESS f/A A/5,E11,1 .'CD T2r4 e-y c,23 &0 Sheet Number Direction Sheet Name C' Z112 Code HOME Or MAILING ADDRESS (if Different from Site Address) 31 3e W 57- 13)ZROAt 904D Street Number Street Name CITY STATE ZIP TAAC c 9s3 PHONE111 Eat. APN# LD USE APPLICATION y_ 115- I ) 83 _ 2 o� � 9 �_ ANNOTA✓AIcABt-E ETI PHONE#2 Fxr. BOS DISTRICT LOCATION CODE CONTRACTOR/ SERVICE REQUESTOR REQUESTOR CHECK K BILLING ADDRESS O N Cy ESN BUSINESS NAME PHONE Pxr' cHEs E co�su�T/,A/6 - o HOME Or MAILING ADDRESS FAX# P O • Fox 3 4 ( ) �loS - ZS98 CITY I L4 Q Lg K STATE // ^ ZIP 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 foam. 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, A E and FED ws. APPLICANT'S SIGNATURE: DATE:,/r' Z D4 PROPERTY/BUSINESS OWNER C1 OPERATOR/ NAGER ❑ HER AUTHORIZED AGENT IB' If APPLICANT is not the BILLING PAR 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: !'UA FACS AAJD 5'66F SU 9,-4 GE G•OI✓Tit M/AIA T/0^//2FPOZ-r- RZC�tl/rzW COMMENTS: J 9/Jo (olAo4 4PAYMENT 9l1�q ,,MECEIVED / JUN 2 4 2004 f SAN JOAQUIN COUNTY ACCEPTED BY: EMPLOYEE#: H L9gT'W'PAR G ASSIGNED TO: EMPLOYEE#:L DATE: Date Service Completed (if already completed): I SERVICE CODE: P I E: Fee Amount: Amount Paid - Payment Date Payment Type Invoice# Check# Received By. EHD 48-02-025 SR FORM(Golden Rod) - REVISED 11/17/2003 - - -