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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH ,.r)PARTMENT SERVICE REQUEST Type of Business or Property �-/ ter/ 77Z FACILITY ID # USINESS NAME I`3 SERVICE REQUEST # T cq�1� PHONE# otv r -.I EM� 7— X03 HOM or MAILING ADDRE S° 72 0 2 5T Date Service Completed (if already completed): FAX FAX# lwcm I TOR Fee Amount: STATE CA ZIP9.9 33 7Z. Payment Date 2 Payment Type CHECK if BILLING ADDRESS FACILITY kAGE fl',th ^ Z)�r�e�_ g 7,7/—/L SITEADDRESS JAA'l7 5. Ar fo,C WAy l -7TfZ- q 5 Street Number Direction tree! Name City Zip Code from Site Address) Ho M or MAILING ADDRESS If pifferre Lent Z r d/urT— _ Street Name Cm �j ` T Zip PHONE#1 Em API / r) 3 USE APPLICATION# �cA* (' PNONE#2 �0 Y9/P / `� / DISTRICT LOCATIO CODE ©) o l of CONTRAC -i .• � :STOR REQUEST G^ ✓� �-/ ter/ 77Z CHECK If BILLING ADDRESS USINESS NAME I`3 Z SocA L �occ4 T cq�1� PHONE# otv r -.I EM� 7— X03 HOM or MAILING ADDRE S° 72 0 2 5T Date Service Completed (if already completed): FAX FAX# lwcm CITY y Fee Amount: STATE CA ZIP9.9 33 7Z. 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 FEDERAL laws. APPLICANT�NATURE: (�jL �� Or ATE: PROPERTY/ 13U ESS OWNER❑ OPERATOR /MANAGER ❑ OTHER AUTHORIZEPAGENT❑ IfAPPLICA,VT is not theBiLLrNG PAR 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 Samjj is provided to me or my representative. Rrn— TYPE OF SERVICE REQUESTED: Apo . COMMENTS: q9p qq TO M ACCEPTED BY: 1 cru-rb EMPLOYEE#: DATE: A_ 'C ASSIGNED TO: LL EMPLOYEE #: DATE: Date Service Completed (if already completed): SERVICE CODE: Dir P / E. l J� Fee Amount: 1 11 J!' o.i Amount Paid Payment Date 2 Payment Type Invoice # Check # Receive By: EHD 48-02-025 REVISED 11/17/2003 SR FORM (Golden Rod) W