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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID# SERVICE REQUEST# s al)g1 OWNER I OPERATOR CHECK If BILLING ADDRESS❑ STEVF— BUCKHOI-Z FACem WE SITE ADDRESS 27-410 M I L.TDN I�oAp 1-/AllaEA1 9x5.2 36 Street Number Direction Street Name City— Zip Code HOME Or MAILING ADDRESS (If Different from Site Address) 2-2o&o /h i LTTJiJ J2oAz> Street Number Street Name CITY /-/A/OEA/ STATE GA ZIP C?152-316- PHONE#1 toPHONE#1 EXT. APN 0 LAND USE APPLic (2oc1) 444, - 08-7 ( 041-3-04o-07W S r PHONE#2 EXT. BOS DISTRICT LOCATION CO2� N ( 1 N CONTRACTOR/ SERVICE REQUESTOR REQUESTOR ,•(vim v CHECK N BILLING ADDRESS© ^ /1/' r'�L r PHONE# EXT. \ h BUSINESS NAME PILL-01V aolIr toy 334-66(3 HOME or MaDNG ADDRESS # P.O. (jox 2I igo (Z ) 3-A {-o77-3 ^ CITY Loo/ STATE C4 ZIP 957Z#I BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, J 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: DATE: 2- PROPERTY PROPERTY/BUSINESS OWNER 13 OPERATOR/MAN ER OTHER AUTHORIT.ED AGENT❑ 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 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. TYPE OF SERVICE REQUESTED: SU4i;W 6 41Vo a FA'CF. <OA?•4Aw11,4Tl44 AE;Oog IV ED COMMENTS: -3/--2 / f 3; tt��L�, FEB 16 200 (y/, % C-.54l�ly O SAN JOAQUIN COU ENVIRONMENTA HEALTH DE/P�ARTME T ACCEPTED BY: (,�„Lq.,�e �ry� (O/ EMPLOYEE#: it)rjoDATE: ASSIGNED TO: ( S EMPLOYEE#: 0 14 DATE: Date Service Complet d (If already completed): SERVICE CODE: + 5 PIE: Fee Amount: 160CC I Amount Paid Payment Date Payment Type Invoice# Check# Received By: - EHD 45-02-025 SR FORM(Golden Rod) REVISED 11117/2003