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SANJOAQUIN COUNTYENVIRONMENTALHEALTHDEPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID# SERVICE REQUEST# S'126(Q `4 8c� �/ OWNER I OPERATOR �R U C � ��.d. "t-� � CHECK If BILLING ADDRESS FACILITY NAME SITE ADDRESS �� o� 57o.-c�c }z't'� �I`( V`t5T 4:- P--06.1> Street Number Direction StreetNam .LEGA M t?o GQ city el 5 Zip Code HOME Or MAILING ADDRESS (If Different from Site Address) P" 15 a X 12Z--1 Street Number Street Name CITY STATE ZIP �ooDl3Q- Ib C--1 ;=—: A 1 S3 $ PHONE#t EXT. APN# LAND USE APPLICATION# t ) UOS— oriof' - L)6, - / C) ! I PHONE#2 EXT. BOS DISTRICT LOCA'n0N CODE ( ) C CONTRACTOR/ SERVICE REQUESTOR REQUESTOR Zc^f'r� 4L Irc 'rC lj I N G CHECK If BILLING ADORES BUSINESS NAME PHGNE# EXT. t5'&(v a a �� :Z6,I d-7` 6 9-r o HOME or MAILING ADDRESS FAx# P1 ---&Iy e 12a7c 139 Cv l ) -I(. CITY - STATE ZIP �hCoap l32lbc-tom CA c► 535 `� 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: tz) ,al"I qul-t— DATE: f I O `� D Ce PROPERTY/BOsiNEss OWNER OPERATOR/MANAGER ❑ OTHER AUTHORtzED AGENT 11 IfAPPL/CANT is not the BILLING PAkz}'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 enviromnental/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: E01 L COMMENTS: �-r-t�c t,-,ham}Bt L t S Ip En/lcy...t N t= E "a�� tS .P72C!-� s�rS �L.�'nI JQ�.Ud ELtJ �`// /7•Q M/ry� c CCv �r r.�FtF ACCEPTED BY: O L-r V E( EMPLOYEE#: 0 3"2-1 DATE O ' ''M y �! O ASSIGNED TO: MEd ! N A EMPLOYEE#: S3 6 DATE: �r Date Service Completed (if already completed): SERVICE CODE: $-y2 PIE: ff-.2-&-O Fee Amount: 1 9 o _ Amount Paid ' 90. 0 D Payment Date Payment Type Invoice# Check# Flo Received By: EHD 48-02-025 SR FORM(Golden Rod) REVISED 11/17/2003