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k3t1 LN .J lJAVUU V UJN 1 1 1`1N V 11(V1N1V1L'1N IIlk I,IJL1 t11.) 1 SERVICE REQUEST Type of Business or Property, FACILITY ID# SERVICE 5JQYEST# I?esic%h4, aI �� .3 Cog/ OWNER/OPERATOR � J CHECK If BILLING ADDRESS ED /T / c7✓I So e Q FACILITY NAME SITE ADDRESS 3 7 S- A'e 1 _/ x/ve Street Number Direction q Street Name Cit Zi Code HOME Or MAILING ADDRESS (If Different from Site Address) Street Number Street Name CITY STATE ZIP PHONE#1 EXT. APN# LAND USE APPLICATION# /83 -32-0 -sG s7 I"A2-s PHONE#2 EXT. BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REOUESTOR F Q N eS/ �. .S i f G CHECK if BILLING ADDRES EXT. 'L BUSINESS NAME G' � F ti�� ' L �,( (,ZPHOo 9 '73 HOME Or MAILING ADDRESS Z Z / h/. (� S-�, B z FAX# (,Z `7) 931-2 CITY /Q /� STATE G/�' ZIP 9 S--2 YO BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent or 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: DATL: 4 - 3 — c 3 PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ OTIIER AuTuORIZ,ED AGEN'IjM Cdy/ L 45s✓6 . If APPLICANT is not the BILLING PARTY,proof of authorization to sigh 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. TYPE OF SERVICE REQUESTED: /feL11e'c.) COMMENTS: 7/1 PAYMENT RECEIVED 141. JUN 2 0 2003 SAN JOAQUIN COUNTY EI PUBLIC HEALTH SERVICES APPROVED BY: EMPLOYEE#: C L DATE: �d d ASSIGNED TO: /t , (� EMPLOYEE#: I112 DATE: Date Service Completed (if already completed): SERVICE CODE: ZZ P/E: n Fee Amount: I Amount Paid /1` Payment Date � P Payment Type ` Invoice# Check# Received By: EHD 48-01-025 SERVICE REQUEST FORM REVISED 6-5-02