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SAN JOAQUIN' )UNTY ENVIRONMENTAL HEALTF 3PARTMENT v SERVICE REQUEST Type of Business or Property FACILITY ID# SERVICE REQUEST# PC-TIL\co \Q59t3/ 5 OWNER I OPERATOR CHECK If BILLING ADDRESS T\-1 o u.k 1>J C>- t S o,-I s FACILITY NAME 1 P A'R-CEL_ S SITE ADDRESS -6--3c,200 f_O S-f C M 2-o xo }} C q 6 j o TR y Street Number Direction I Street Name city Zip Code HOME or MAILING ADDRESS (If Different from Site Address) Street Number Street Name CITY STATE - ZIP PHONE#t Err- APN# USE APPLICATION# I > — 2 S MS PHONE#2 Exr. BOS DISTRICT LOCATION CODE ( ) CONTRACTOR/ SERVICE REQUESTOR REQUESTOR J � 5 CHECK If BILLING ADDRESS o�� ET�rLN� - D,• - 1�a�5a>z >-tAaA� BUSINESS NAMEPHONE# �' R.b. wE� o �v Sbcr- ,j re S ZUR IS t9s IS HOME or MAILING ADDRESS S2 3i� s R�C�' ( X# y23 - 3383 CITY M ODZ5-�o STATE G A ZIP 1 5 354 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, TATE and FEDERAL laws. APPLICANT'S SIGNATURE: (i DAT(E�:( / " / ?, - D PROPERTY/BUSINESS OWNER❑ OPERATOR/NIANAGER 11OTHER AUTHORIZEDACENTICI Ger ¢3J C b IfAPPLICANT is no a 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 environmental/site assessment information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as Soon as it is available g afn ane time it is provided to me or my representative. l t�/t"alim TYPE OF SERVICE REQUESTED: 5L4 r 4 COMMENTS: LN..t,r�Qj`GF I SJ % S J f2�rQ-C.E TIS FO JF- y Y O �f1 QUICI COUNTY A r10 A E N J 1 I2.a Ito VA tki -l_ CLie, O3 - 3 f 4 ��"'�, � R24pta HAJOATH pNM TML Errr ACCEPTED BY: C'Li Llic r pt?4 EMPLOYEE#: ©3 DATE: Ir ir s(d /E ASSIGNED TO: 1 SS EMPLOYEE#: DATE: Ll Gy Date Service Completed (if already completed): SERVICE COOS: �i5 PIE: i7-3 Fee Amount: I 00 Amount Paid _ Payment Date _ Payment Type Invoice# Check# Received By: EHD 48-02-025 SR FORM(Golden Rod) REVISED 1111712003