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aHl-4 JUAk IL11iV q-V9 111 JCdVV11CVIV1VIL'IV1Hll Ell:PALltl LL'1'H1�1lViL'lVl SERVICE REQUEST •1 Type of Business or Property FACILITY ID# SERVICE REQUEST If OWNER I OPERATOR CHECK if BILLING ADDRESS El C— V i2r ,= s- =vic . FACILITY NAME ''('' 95'63 SITE ADORESS2�6 ` 6 IV. J Q G k-t� 4:2 It�1 C�G Z OC Street Number Direction Street Name' / Cit 21 Cotle HOME or MAILING ADDRESS (It Different from Site Address) D Z Street Number Street Name CITY I� STATE ZIP c 9 63 z PHONE#t "T. APN# LAND USE APPLICATION# PA OZ X379 PHONE#2 En. BOS DISTRICTLOCATION CODE ( ) CONTRACTOR/SERVICE REQUESTOR REQUESTOR CHECK it BILLING ADDRESS Olrvt C.S'f' �. CJ t/KL PHONE# EXT. BUSINESS NAME f 3!—/3 HOME Or MAILING ADDRESS FAX# Zz, UJ . axe- 4LB-Z- ( CITY STATE ZIP 7 SZ4ee-, O 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: �Oy J ! • DATE: -� PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT�G,iytc- FNcog, If APPLICANT is Hot the BIUJNG 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 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. ( 1- TYPE OF SERVICE REQUESTED: COMMENTS: CM a t lcd 7 e, E6_f Itto 003 ��G.jZ%(r'c.✓ �7/ �hr+•',3 rera�rPit 1I5 GGUCIT" _Jr.-�r -�-•- _rr:.� .�r /yLr�--. x .�-''r»t.�3 nti v l aN�':A�A,H sC P,v1c��,.: ee- M. APPROVED BY: w El PLOYEE#: LL,Y� DATE: tFeee NED TO: I C� D PLOYEE#: y 6 DATE: t..r' 'Z9 -3 J [ Service Completed (If already completed): SERVICE CODE: J �� P/E: bU mount: `I Amount Paid 'i<, --i Payment aef3 b'Jent Type Invoice# Check# 3 b Received ey:2�_.