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SAN JOAQUIllipUNTY ENVIRONMENTAL HEALTI: -PARTMENT SERVICE REQUEST Type of Business or Property t...UY-1 CAA Way 0 FACILITY ID # if voolio SERVICE REQUEST # a us-PI oi.D OWNER / OPERATOR Varr) oin a ,ewe CHECK if vo BILLING ADDRESS P FACILITY NAME \ e1rOSYCil St 3-- SITE ADDRESS 1 3-3 ‘ Street Number S , Direction i \,,,i -k ‘SOn VNic-L'i Street Name Stu c- te---t0Y-\ City 415 2.05 Zio Code HOME Or MAILING ADDRESS (If Different from Site Address) 1 --)' % Street Number 5 V\J . 1Goft. rAtA/9 Street Name CITY cn,w...4,...) STATE CA ZIP til S '2-0 S PHONE #1 T. U/) .2%-1 2- - 7c‘q APN # LAND USE APPLICATION # PHONE #2 En. ( ) BOS DISTRICI LOCATION CODE CONTRACTOR / SERVICE REQUEST OR REQUESTOR .P air on Et iketfreru CHECK if BILLING ADDRESS BUSINESS NAME 1 eiru \l'-e-rIS PHONE # ( Zi)or ) Ext. '2-42.- - 1-0 lq e HOME or MAILING ADDRESS 1 3*-, ‘ c.. 1.4 i I So r--) Fax # ( I Crre• ,-- , _ vial STATE Ca - ZIP C15205 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 FEDERAL laws. 1c47W DATE: PROPERTY / BUSINESS OWNER2 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 assessment information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and aNprne time it is provided to me or my representative. -4`4.."•11-'1 1vp TYPE OF SERVICE REQUESTED: fl,..c pec ciQt-) i ‘' net COMMENTS: , D 6114/do '' S 2/ms iid414Q0 via' --ictifoc24/4-404/4/ 4%. ACCEPTED BY: 1 . yyk 0 ,A[2,,„\ 0 EMPLOYEE #: DATE: 10,2 CH ASSIGNED TO: . 44 VI \1:1•1 \A- EMPLOYEE #: DATE: Ikk.) Date Service Completed (if already completed): SERVICE CODE: cx,_, \ P1 E: Fee Amount: ti!ir c5Z c3 Amount Paidc /s07, b D Payment Date ).6 .21 / 7 Payment Type ele Invoice # Check # 2gz_/_ff Recel ed By: APPLICANT'S SIGNATURE: osu• 4t SR FORM (Golden Rod) EHD 48-02-025 REVISED 11/17/2003