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SAN JOAQUII _ —OUNTY ENVIRONMENTAL HEALTH _—PARTMENT SERVICE REQUEST Type of Business or Property JI'`O-e— l �'C'1r ,;V A,/�n/)�� FACILITY ID # SERVICE REQUEST # }} /� 2 C.(/l� -j1' I"[� I .J� PHONE# !FA oo 23-Zy-z Ga UOg I +A -Z OWNER /OPERATOR,�l!^ I -1 'V (�I v ` CHECK If BILLING ADORESSO A FACILITY NAME SvAv�l� `C C I"eo �1 � J25-72 SITE ADDRESS F- /1 „�"�`P�1 A�j� .�T CJ�1 l Gy. ,- 1 l"R�"t61' Gs-�S Street Number Direction teal Name ('lra.� Zip Code HOME or MAILING ADDRESS (If Different from Site Address) (0 I , I I L 0 f.v--m 'l n Payment Type Street Number Street Name CITY ^,, _, `�./y�( STATE C ZIP �Z) 0 PH ET. APN # LAND USE AP/PLLIICATION # -v lOiNNEE#�1 (2) (p l - S)` A - PHONE #2 EXT. BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR N�( r�l� JI'`O-e— l �'C'1r ,;V A,/�n/)�� CHECK if BILLING ADDRESS BUSINESS NAME �A V, `^ I ' }} /� 2 C.(/l� -j1' I"[� I .J� PHONE# , I En. `l HOME Or MAILING ADDRESS DATE: 1 -2 FAX# J CITY STATE an LP q S-Zl V BILLING ACKNOWLEDGEMENT: 1, 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 TATE and FEDERAL laws. APPLICANT'S SIGNATURE: f I & k "� , DATE: PROPERTY/ BUSINESS OWNER❑ OPERATOR/MANAGER❑✓ OTHER AUTHORIZED AGENT 13 /f 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. a._ TYPE OF SERVICE REQUESTED: V G (n(�I COMMENTS: I C e co. -Cn a\ IvA �v lL AGic�1 N� �e� vtcl� 'De�ek� 202�OF_ 1 'Y✓Y � Y 'I Ami 131 `�E 'bAv, 1019 M ryoe"p e �, ACCEPTED BY: OAQ /) 3 v, w • 4 EMPLOYEE#: DATE: 1 -2 ASSIGNED TO: ` / J EMPLOYEE M DATE: Date Service Completed (If already completed): SERVICE CODE: PIE: 1 �� Fee Amount:. n-2Amount Paid ('lra.� Payment Date 1 2 1 Payment Type Invoice # I Check # Received By: EHD 48-02-025 REVISED 11/17/2003 IV SR FORM (Golden Rod)