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SAN- . OAQOCOUNTY ENVIRONMENTAL HEAL DEPARTMENT SERVICE REQUEST Type of Business or Property CHECK if BILLING ADDRESS FACILITY ID # COMMENTS: s SERVICE REQUEST # HOME or MAILING ADDRESS FAx # .O_ IE;G IOZ!�__ OWNER / OPERATOR CITY I r s; ^-,- 5-"� CHECK If BILLING ADDRESS❑ / -1— ENVIRONMENTAL FACILITY NAME Q ACCEPTED BY: Q I f SITE ADDRESS I DATE: p dS- ASSIGNED TO: V Q v 36 S 0 �- Street Number Direction Street Name -City Zio Code HOME or MAILING ADDRESS (If Different from Site Address) Amount Paid ►a f E (- P ILc s 1�__ ST- - 6 Street Number Invoice # Street Name CITY /tL E_ VA m--1_ r — STATE C a- ZIP /, Vs— 3 0— ExT• PHONE #1 APN # LAND USE APPLICATION # ( Sro) 6 S}- �s10 o PHONE #2 ExT• ( ) BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR A,r t C r, Ar cA_ ' , ` ^ � O . r �/�/' UY W 1T M VM CHECK if BILLING ADDRESS BUSINESS NAME (Al io tALEE2/mac<<, 17�E-c _ COMMENTS: s PHONE# EXT. 9t6 -3 }3—I<rZ HOME or MAILING ADDRESS FAx # .O_ IE;G IOZ!�__ (cf(6)34-3—Ic�Z CITY I r s; ^-,- 5-"� STATE CA, zip C/s-6 Ct 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 F DERAL laws. / APPLICANT'S SIGNATURE: DATE: j PROPERTY / BUSINESS OWNER OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT LYI �' QnA7�j� &'C%rO 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 time it is provided to me or my representative. TYPE OF SERVICE REQUESTED: _ COMMENTS: s /_%� %---Rr_0f--1 ED JUN 2 8 2005 SAN JOAQUIN COUNTY ENVIRONMENTAL ACCEPTED BY: Q I f EMPLOYEE #:Q "�-Z I DATE: p dS- ASSIGNED TO: V Q v EMPLOYEE #: i -7 DATE: 2_. Date Service Completed (if already Completed: SERVICE CODE: ! Q P I E: Fee Amount: �� w Amount Paid Payment Date Payment Type Invoice # Check # JT — Receive By: EHD 48-02-025 SR FORM (Golden Rod)\