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is SAN JOAQU OUNTY ENYIRoNMENTAL HEALWEPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID # ' CHECK If BILLING ADDRESS ' SERVICE REQUEST # 'C�-&Z BUSINESS NAMEl LL •t c' 1 OWNER I OPERATOR x n r� v `( W EXT' (�� --&,3,39 6,3 CHECK if BILLING ADDRESS FACILITY NAME STATE r'-' I% ZIP 9 5Zo SITE ADDRESS �� ACCEPTED BY: t u) c .tet _! 6.2`k) StreeNu t mber Direction ASSIGNED TO: Street Name Ci 2i Code HOME or MAILING ADDRESS (If Different from Site Address) DATE: f / Qac - Date Service Completed (if already completed): SERVICE CODE: Street Number Fee Amount: Street Name CITY STATE ZIP Y PHONE #i EXT. (M) ,��o'' et� APN # (�`f S` « O� LAND USE APPLICATION # PHONE#2 EXT. Invoice # BOS DISTRICT / LOCATION CODE Received By: z�' CONTRACTOR/ QUESTOR REQUESTOR / �= r ' CHECK If BILLING ADDRESS ' C BUSINESS NAMEl LL •t c' 1 PHONE# 1 FAx# ) EXT' (�� --&,3,39 6,3 HOME or MAILING ADDRESS , CITY dC I STATE r'-' I% ZIP 9 5Zo 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, Standarde,TATE and FEDERAL laws. APPLICANT'S SIGNAT , DATE:. -d '7 — 0f?9 PROPERTY/ BUSINESS OWNER ❑ OPERATOR/ MANAGER ® OTHER AUTHORIZED AGENTO i *,- {,C Lei IIc )� �Ci7i Y If APPLICANT is not the BILLING PARTY proof of authorization to sign is required Title AUTHORIZATION TO RELEASE INT`ORMATION: 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 environmentaYsite assessment information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available 8u the same time it is provided to me or my representative. PP*`�PtC\/tea TYPE OF SERVICE REQUESTED: t.,s'�'.G �= r C. COMMENTS: ,A p Coovy SAN JOAOUIN Et�C HFfwAtYti aEPAki� ACCEPTED BY: t u) c .tet EMPLOYEE #: DATE: 5- . ,71ve ASSIGNED TO: (Z- C_A� / EMPLOYEE #: 14-1 2--2- DATE: f / Qac - Date Service Completed (if already completed): SERVICE CODE: Fee Amount: -.1 �r ,bZ Amount Paid V� < < _'; `'�� Payment Date ' , ' .. 9-f Payment Type �' Invoice # Check # -: Received By: z�' EHD 48-02-025 REVISED 11/17/2003 SR FORM (Golden Rod) i'- - d 21b69 T 9-b60Z 0u I S -1040e.141-100 Al a4 T 13 d90 : T 0 20 06 unr