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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID# SERVICE REQUEST# OWNER/OPERATOR CHECK If BILLING ADDRESS 13/ M n N I R M FACILITY NAME SITE ADDRESS 2� FiZ�N�N CAMP JZpap FRE/✓G14 e_4►ne 85331. Street Number Direction Street Name City I zip Qode HOME or MAILING ADDRESS (If Different from Site Address) 7 q,90 /nO RPH/ PA 914-W4y Street Number Street Name CITY � ^TP RO l STATE ZIP s P4ig,NE#1 Nt E'�T APN# LAND USE APPLICATION# ) 3SS- I23 -D70 - L4 PA -19002-5-1 PHONE#2 EXT. BOS DISTRICT I LOCATION CODE CONTRACTOR / SERVICE REQUESTOR n REQUESTOR CHECK If BILLING ADDRESS W Ktt I/VO MAL44AIr BUSINESS NAMEPH,QNE# EXT, C M c-am "T 5S-5 00 HOME or MAILING ADDRESS FAX# 1 7 o a ( ) CITY / ^T-74 WE STATE ZIP 1-5-330-5- a BILLING ACKNOWLEDGEMENT: 1, the undersigned property or business owner, operator Or authorized agent of same, acknowledge that all site and/or project specific ENVIRONN•1ENTAI..HEALTH DF..PARTNIEN'r 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 JUAQUIN COUNTY Ordinance Codes,Slaneiardc, STAT' d FEDERAL laws. APPLICANT'S SIGNATURE: 11,1W4 DATE:�/.,t !a ZZ PRONFR'1'1'/I;USINF.SS OwtiF:R� OPERATOR/MA\AGER ❑ OTHER AU'rHORIl.ED AC:F.\'r❑ Ij'1 PPLIC ANT is not the BILLING P.IRTY,proojnf'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 ENVIRONNIFNTA1 FllEALTtt DETART11`1EN'r as soon as it is available anPA $� 40NTe time it is provided to me or my representative. S� TYPE OF SERVICE REQUESTED: COMMENTS: 10 Luili DEC SAN J0P'QU1N COUNTY EMIIRONME TTAi MENT HE)'�TH DEPAR ACCEPTED BY: EMPLOYEE#: DATE: ASSIGNED TO: EMPLOYEE#: DATE: Date Service Completed (if already completed): SERVICE CODE: v P E: Fee Amoun Amount Paid 3 Payment ate L Payment TypeG �/I� Invoice# Check#'V Aph $Gr' 4 Received By: EHD 48-02-025 ` Sk 4'4 w LPZ4,f:j'6 SR FORM(Golden Rod) REVISED 11/17/2003 {� 1 ��2 �.