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SAN JOAQUIWUNTY ENVIRONMENTAL HEALTH9PARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID # SERVICE REQUEST # QG-TA•(L F VEL DOS f2- HOME or MAILING ADDRESS ACCEPTED BY: -7 OWNER/ OPERATOR / DATE: 16 (cft(, ) 343 - /(1-2— 1— ET E C` 2 A� F r - I (0 N CHECK if BILLING ADDRESS FACILITY NAME F L A W A_ rz T -- Date Service Completed (if already completed): SITE ADDRESS '� E*'TL F "A A t4 L Fee Amount: Amount Paid 9-7 7. (D Payment Date J 1) 'L -?11) 3 C 1 Street Number Direction Street Name Check # 3 (117 city Zi Code HOME Or MAILING ADDRESS (If Different from Site Address) S A Street Number Street Name CITY STATE ZIP PHONE #1 EXT. APN # LAND USE APPLICATION # (Zo9) 3314 - 3Z33 PHONE #2 EXT ( ) BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR (C � A, F, L w� L�0 Y+'M Ij CHECK If BILLING ADDRESS 1�v BUSINESS NAME w A LTo �( t✓l,(GIrlEEI2r►L�, COMMENTS: PHONE # EXT. 11(o 3*43 HOME or MAILING ADDRESS ACCEPTED BY: FAX # -P.0. V0X 1C) / DATE: 16 (cft(, ) 343 - /(1-2— CITY I r 2 A�� STATE C A ZIP C? S 6 Cr 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 FEDE laws. APPLICANT'S SIGNATURE: �I I-- DATE: / O 0 p PROPERTY / BUSINESS OWNER❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT Lpl c0 ?'LT P'C7S 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 at the same ime it is provided to me or my representative.(gyp: AMEN —�, irf TYPE OF SERVICE REQUESTED: 'PL A'4 7 (> E X0'4 COMMENTS: JAN 0 3 2� SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT ACCEPTED BY: EMPLOYEE #: 2 elb / DATE: 16 ASSIGNED TO: L o rL t L V C e, S EMPLOYEE #: DATE: 3 Date Service Completed (if already completed): SERVICE CODE. b P / E: 51 Fee Amount: Amount Paid 9-7 7. (D Payment Date J 1) 'L -?11) Payment Type Invoice # Check # 3 (117 Received By: EHD 48-02-025 SR FORM (Golden Rod) REVISED 11/17/2003