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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID# SERVICE REQUEST# RC- 5/ked 7-1A L OWNER/OPERATOR CHECK If BILLING ADDRESS 1771 . s; /nATT kEENAAJ FACILITY NAME SITE ADDRESS a/3 a-0 S FRF-pF-iZ1 4-- A Ve • X'/P9/A4 g.ST 6f'p StreetNumber I Direction Street Name city de HOME or MAILING ADDRESS (If Different from Site Address) Street Number Street Name CITY STATE ZIP PHONE#1 EXT. APN# LAND USE APPLICATION# (oZoq ) 345-- fa2v,�2- 1 67-51-7- 2b0-11 4B PHONE#2 EXT. BOS DISTRICT LOCATION CODE ( ) CONTRACTOR / SERVICE REQUESTOR REQUESTOR �J I l O&/V t , CHECK if BILLING ADDRESSO BUSINESS NAME (/ ✓/v PHONE# EXT. C'On(SuLr ao o2 -t'65� HOME or MAILING AD RESS FAX# o . 3 ( I CITY STATE ^ zip +5301 BILLING ACKNOWLEDGEMENT: 1, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or project specific ENVIRONMENTAi..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 JOAQIIIN COUNTY Ordinance Codes,Standards,STATE and FEDERAL,laws. APPLICANT'S SIGNATURE: DATE: l D '02l'oZ aeL d PROPERTY/BUSINESS OWNER L7 O ERA'roR/MANAGER ❑ OTHERAUTHORIZEDAGENT❑ IfAPPLICANT is not the i31t LLN'G PAR77 proof of authorization to sign is required Title AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1,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 HEALTit DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. My T TYPE OF SERVICE REQUESTED:Soil 5 U/TA8/L t N/r9 ATE Lo D/N leatllew Ram—C p COMMENTS: OCT 2 1 2 20 SAN JOAQUIN COUNTY ENVIRONMENTkL HEALTH DEPART&IENT ACCEPTED BY: Z— EMPLOYEE M DATE: /o k Ill]a,�o ASSIGNED TO: S S EMPLOYEE#: DATE:Nh/ do C) Date Service Completed (if already completed): SERVICE CODE: Sa 31 1 i E: Os Q Fee Amount: �� Amount Paid —. Payment Date d Payment Type Invoice# Check# Received B EHD 48-02-025 SR FORM(Golden Rod) REVISED 11/17/2003