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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property tExT. BUSINESS NAM G ( 1� 1 FACILITY ID # 6�� HOME Or MAI TNG AD Ql(SS J'_� lo' /IYu SERVICE REQUEST # sro; k�Uk MV ZIP OA 5 �� ACCEPTED BY: ka c16s OWNER / OPERATOR \I EMPLOYEE #: �J DATE: n P (/ CHECK if BILLING ADDRESS E] v �p C EMPLOYEE #: DATE: FACILITY NAME CU t P I E: 1 ' -n- VI l Amount Paid �� U� l EADDRESS '175 C LI s1 l.\ Ui Invoice # ��-I,.p�I �(� l I� i G� l 0 Street Number Direction Street Name Clt ZI Cotle HOME or MAILING ADDT.SNIff Different fr m Sitedress) 1� \l _01 1 l- Street Number Street Name CI S7 7 ZIP ZOl A P�HH/nONNEE' #1 ExT. APN # LAND USE APPLICATION # PHONE#2 EXT. SOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR I�� n 6 �J ' ` CHECK If BILLING ADDRESS REQUESTOR%%6t tExT. BUSINESS NAM G ( 1� 1 PHONE # 09 HOME Or MAI TNG AD Ql(SS J'_� lo' /IYu fAX# ) CITY STATE ZIP OA BILLING ACKNOWLEDGEMENT: 1, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or project Specific ENVIRONMENTAL HEALTH DEPAR'T'MENT hourly charges associated with this project or activity will be billed to me or my business as identified on this form. 1 also certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQL IN COUNTY Ordinance Codes, Standards STATE and FGD -RAL laws. (� J APPLICANT'S SIGNATURE: �iG DATE: —112�I PROPER"rY/BUSINESSOWNER OPERATOR/ MANAGER ❑ O"rnERAtrinORizro AGENT❑ IfAPPL/CANT is not the BILLING PART)" proof of authorization to sign is required Title AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, 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 arthe same time it is provided to me or my representative. IJAy TYPE OF SERVICE REQUESTED: �Y1 S Vt f on xt-CFS COMMENTS: GV W 0 �w' (� p2820 H�tNot0P&III�fv-r IV gRqN ACCEPTED BY: ka EMPLOYEE #: �J DATE: n P (/ ASSIGNED TO:kA,d ✓1 EMPLOYEE #: DATE: Date Service Completed (if already) completed): SERVICE CODE: P I E: 1 Fee Amount: Qp Amount Paid �� U� l Payment Date�;� Payment Type 5� Invoice # Check # ' I L SO Received By: EHD 45-02-025 SR FORM (Golden Rod) REVISED 11/17/2003 S