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I SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID# SERVICE REQUEST# L C�s.�to1.INE 1647 lt>/-1 _� to S'�o01//2-LfLf— OWNER/ OWNER/OPERATOR e6P w EsT cC�A�j? CHECK if BILLING ADDRESS E] FACILITY NAME OW Ai&-`—O9'Q SITE ADDRESSE L,.OvI S0 �•�E t_,�.TF-1 P`of� �se�I Street Number Direction Street Name Cit Zi Code HOME or MAILING ADDRESS (If Different from Site Address) `74„7 SI 1 Xf LI2 GT Street Number Street Name CITY STATE ZIP Ipv lal�l � c,c., ��6LQ3 PHONE#1 EXT. APN# LAND USE APPLICATION# ( cap -T S r✓F PHONE#2 EXT. BOS DISTRICT LOCATION CODE ( ) CONTRACTOR / SERVICE REQUESTOR REQUESTOR l..l 17I7`J� MGi�E�I Z t 6 CHECK If BILLING ADDRESS BUSINESS NAME G PHONE# EXT, SS, S�r...7' HOME or MAILING ADDRESS FAx# G�747 S 16 tzRr►- �-r, (OM& S 51 . Z fa4�8 CITY STATE G.� ZIP BILLING ACKNOWLEDGEMENT: 1, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or project specific ENVIRONMENTAL HEALTI-I 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 1 have prepared this application and th e work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes,Standards,STATE and F L laws. APPLICANT'S SIGNATURE: DATE: I O/tom/1 b PROPERTY/BUSINESS OWNER❑ OPERATOR/NIANAGER ❑ OTHER AUTHORIZED AGENT❑ ff APPLICANT is not the BILLING PARTY proof of authorization to sign is required Title p�Ry�� AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1,the owner or operator of the pro per�l� t the above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/s IIp4 information to the SAN JOAQUIN COUNTY ENVIRONME TAL HEALTH DEPARTMENT as soon as it is available and at�Cpae tl s provided to me or my representative. us7j A r'/ N 6- //,.jS7-A-C L.-4!T-7 v ;J TYPE OF SERVICE REQUESTED: U 5T1 tl6TP•�1-.�'.T O A.I N�C /90 U/lV C COMMENTS: P' fV7;( �I..Is�rt�t,1.��Z� rJ 3T- pt+.16 Z7�a100 C�O►L,1.OIIJ rrL.1 T C l Zll o0o C.e.u_.owl FNr r P-6t-A%uMl&0 000 C.^L4.6N PiS05,6 L,) ^ C:>0 Zoe oo o Gri+1..�o N F�Ecut.r•R. . �I.a 9TA L t. `4) IIJ E w M P v�/t�L�•tJ Pc /V IDG`S, . LI-4 g.'04 t.rt_. II.1 Cm W S►VMIrg* A 4 fl P i PI, G fib 18 LAb'#'! pqw- . . (VN 11 co-,P w/t S O ACCEPTED BY: �� J l=[ �'T EMPLOYEE#: C) 3 Lr DATE: to I I Q ASSIGNED TO: r 1 EMPLOYEE#: "Zf_("4 DATE: ( U /.I t 4L) Date Service Completed (if already completed): SERVICE CODE: 03? P I E: (V3 Fee Fee Amount: Amount Paid O Payment Date l© D Payment Type Invoice# Check# Received By: EHD 48-02-025 SR FORM(Golden Rod) REVISED 11/17/2003