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SAN JOAQUIN OUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property I CU 0 FACILITY ID # SERVICE REQUEST # OWNER! OPERATOR ^ \ •_. , (A_ IA( --)--e\- Di 1 t \, CHECK if BILLING ADDRESS FACILITY NAME SITE ADDRESS l' L' Street Number Direction I S4( d' 4 at 641— ) 2)--} _ Street Name L-0 a (s, City cis -L(16 Zip Code HOME or MAILING ADDRESS (If Different from Site Address) <67 Street Number Street Name CITY STATE\ ZIP /1 1S2- 0 (1 PHONE #1 Ex-r. ()I APN # LAND USE APPLICATION # PHONE #2 Exr. ( ) BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR r l " CHECK if BILLING ADDRESStgf BUSINESS NAME PHONE # ,_ EXT. HOME or MAILING ADDRESS ,) `,.) 3 Li E . FAX # CITY 3)o ( le--o )--) STATE - , 0 ZIP CI'S/ ?(/ 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 Of 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' WU/1;4n j cMO.. DATE: .) PROPERTY! BUSINESS OWNER OPERATOR! MANAGER 0 OTHER AUTHORIZED AGENT 0 If APPLICANT is not the BILLING PARTY 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 environmental/site assessw4ormation to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is or my representative. R TYPE OF SERVICE REQUESTED: --a73,,1-----e7:c_ct Cblis t_ tct -41 6 r -1 ICE -.....civt COMMENTS: sAN a 4u1? CJAartqz C c- 01,07)-er 4-4,11 wu,A, Htit.r RoAtit, couN, Hozp eivrk. , r Ali Noir ACCEPTED BY:1,--(71 EMPLOYEE #: DATE: & i i ASSIGNED TO: 1 ../3 0 ryCk EMPLOYEE #: DATE: ,...7 . 62 , / 7 Date Service Completed (iialready completed): SERVICE CODE: C V / P/E:),./._. Fee Amount: , 7--- ! , — Amount Paid Payment Date Payment Type Invoice # Check # Received By: END 48-02-025 07/17/08 s Jo SR FORM (Golden Rod)