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SANJOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVIC.F REQUEST _ Type of Business or Property FACILITY ID# SERVICE REQUEST# F'ASTtiR•E � Nor�+E s,�.e AJ'N`. oa$-009- 5� x,20031 (o .� � OWNER/OPERATOR R68eaT W. 'TOY'[EeRS CHECK If BILLINGAODRESSE] FACILITY NAME SITE ADDRESS d 9 Street Number Direction 1=RT F Slreet Na e R6A� /1CAMPO 9.S Ci Zi Code HOME or MAILING ADDRESS (If Different from Site Address) GA.S Street Number TR E izT 3treet-1412M CITYm REDDIN6 STATE CA ZIP l� 7 9 b Owl PHONE#'I {�oGi7v- 7OW�, T• APN# LAND USE APPL ATION# (2(>9 ) -S2,4- 939t oos- �� - m--C" PHONE#2 ExT SOS DISTRICT LOCATION CODE ( ) CONTRACTOR/ SERVICE REQUESTOR REQUESTOR (� C u Q-n 5 CHECK If BILLING ADDRESS BUSINESS NAME 4- Ia MA��`y/ -{ll ^7� P2NE# �sT' HOME or MAILING ADDRESS FAX# CITY 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 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: 6- 6 2a Z PROPERTY/BUSINESS OWNER❑ OPERATOR r MANAGER ❑ OTHER AUTHORIZED AGENT I[� GIYIL F'Iv ILEF;-i Q_ If AFPLICANT is not the BILLING PARTY proof of authorization to sign is required Tote 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 enviroamentaVsite 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: REVIEY,W 1j SVR•�f.G;c. At4l) 5Q%,50R�A,G� CONT rl COMMENTS: V.Acy'we %"� �et�` '� �, nc'rP° 224002 "rI M- a� cI^' /� Nf711�v,5 , SAN JOAOUIN COUNTY .ttd d1VICES L r 9 ^ n FN'4RONMENIBLIC P HEALTH TH DMSION r� C�' �3 APPROVED BY: EMPLOYEE#: 9(p 9 DATE: ASSIGNED TO: -F7A-S/O O o%rC EMPLOYEE#: L, DATE: (Q_22 / Date Service Completed (if already comp(eted): •�-C7GV SERVICE CODE: 315 P/E: -�)(o03 Fee Amount: I E)CKD Amount Paid 1 -78 cc' Payment Date D a G L3, PaymentType Invoice# Check# '? Received By: EHD 48-01-025 SERVICE REQUEST FORM j REVISED 6502