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DATE: //W)/2.1•3 ( OTHER AUTHORIZED AGENT 0 SAN JOAQU _ COUNTY ENVIRONMENTAL HEALTIDEPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID # SERVICE REQUEST # ---3R 0 0 Y>( 5 -:1-(--1 OWNER! OPERATOR C1-3 r-"A OIT 5 --1/1 -erecet- CHECK if BILLING ADDRESS FACILITY NAME s4 1,012 a\ c..... (Y? cc LAC,4 L-I i-•I L-I 001 2_ (A-IfAilx e) SITE ADDRESS Street Number .".•.) Direction -1 4-1,\ i-- Street Name moctes1-0 City Ol S-35 I i Zio Code HOME Of MAILING ADDRESS (If Different from Site Address) Street Number C ko,i-e4Q Street Name PrA Cirif if\i/Va- STATE ZIP PHONE #1 EXT. APN # LAND USE APPLICATION # ( ) PHONE #2 #2 EXT. BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR k P,Apci-D r'l 0AeS 4U-ei-e,c6 .- A CHECK if BILLING ADDREssj2:1, BUSINESS NAME $6 k),7 CU( tAPIC1 c 0 PH9pqt ( 'Al ) Err. — 2L I ---/- HOME or MAILING ADDRESS 2.11_ te,1 . C I UfAti-- e-ei • FAX # ( ) CITY -ho A-(A/A- sTATc4 ZIP ot -35 1 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 DERAL laws. APPLICANT'S SIGNATURE: PROPERTY / BUSINESS OWNER 0 OPERATOR/ MANAGER 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 environm%tal/site assessment information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available andETA411111tArfne it is provided to me or my representative. TYPE OF SERVICE REQUESTED: \--00C11 v_e In; i, '' —164 VQ) ._., COMMENTS: , , J 0 2 019 Uvmviy. 0' 00W,tee-c,,e sANJoA Qui,,,- H ENwRoN couNry E1LTH opiticivrAt AR TA4sAir ACCEPTED BY: \.1 . \NI D.A.QA(V 3 ' EMPLOYEE #: DATE: ASSIGNED TO: \I • )-Ctil\WLD EMPLOYEE #: DATE: Date Service Completed (if already completed): SERVICE CODE: c) cc, ( PIE: Fee Amount: • 0-2 'D Amount Paid i --Z----- Payment Date Payment Type ebi i--- 1 Invoice # 9Ine?g:jtjzti- 102teezt12-4) Received By: r EHD 48-02-025 SR FORM (Golden Rod) REVISED 11/17/2003