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SAN JOAQUIN OUNTY ENVIRONMENTAL HEALTH DARTMENT SERVICE REOUEST Type of Business or Property FACILITY ID # BUSINESS NAME Mate - SERVICE REQUEST # C-zAS s -t -k -«o m 3-7 9-6 DATE: 7�5�! CITY S, -,-La T . ES0 K, STATE C, t 6- /03 ZIP !'l-�V . DATE: c� 2 � (0-7 OWNER / OPERATOR `^ 1' c-y� `vc K © Lk �Lt—ct CHECK If BILLING ADDRESS❑ FACILITY NAME FJl V� �Lr`eb Fee Amount: Lfc� SITE ADDRESSZi `��Street L& Payment Type ✓ Invoice # �— Number Direction Street Name Ci Code HOME Or MAILING ADDRESS (If Different from Site Address) Streel Number Street Name CITY STATE Zip PHONE #1 Exr. GUM � -W- 710% qpN # �� _ 3 LAND USE APPLICATION # PHONE #2 ExT. BOS DISTRICT LOCATI� CODE (:(MTRAUTUM / RF.RVTCF. RF.nTTV.Q rnD REQUESTOR CHECK If BILLING ADDRESS BUSINESS NAME Mate - PHONE# Exr. HOME or MAILING ADDRESS 0 a!- k cauaf tom' k DATE: FAX # ( o%) Ql3- �c� alp CITY S, -,-La T . ES0 K, STATE C, t 6- /03 ZIP !'l-�V 131LLENki ACKNQWLEllGEMENT: 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 t}in- have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQurN COUNTY Ordinance es, Standards, STATE and FEDERAL laws. APELICANT.'S SIGNATURE:. DATE:. PROPERTY / BUSINESS OWNER❑ OPERATOR /MANAGER ❑ OTHER AUTHORIZED AGENT '- "i"""- 4z, Q . If APPL/CANT 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 locate above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site as§e information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same ti��lis2t 200? provided to me or my representative. . N COl1NTY MENTAL EPARTMENT TYPE OF SERVICE REQUESTED: az,—r-(-96,C ( T . n,A COMMENTS: ( . �S� c -B ['� $g i �'�X `�s Y `C(71/` � �11J 'L `�C?l.t. SLI rte S ENVIR ,� �� H l ACCEPTED BY: C) L EMPLOYEE M L DATE: ASSIGNED TO: E --q� EMPLOYEE #: . DATE: c� 2 � (0-7 Date Service Completed (i already completed): SERVICE CODE: i C �i (ment P / E: Fee Amount: Lfc� Amount Paid is g"7 t f` � Pay Date q () -7 Payment Type ✓ Invoice # Check # Received By: -h-L EHD 48-02-025 REVISED 11/17/2003 SR FORM (Golden Rod)