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d t 4 SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID# SERVICE REQUEST# I / T 0 t7 12Z� Z S L�0 01 LA OWNER 1 OPERATOR �^ /�'� V Y I V (I ,� ,� ,� A I�(A I� CHECK If BILLING ADDRESS FACILITY NAME i �ZOI C��v��j � i V (Ak1{—e+ � C Yt Ie'm I ce V"- eA' SITE ADDRESS2206 n`101 t vi - �4'lc�] Street Number I Direction Street Name City Zi Code HOME or MAILING ADDRESS (If Different from Site Address) Il Street Number Sleet Name CITY STATE K C ZIP OZ(D 'moi t/{y l/�'� '�1 PHONE#1 a EXT: qpN# LAND USE APPLICATION# PHONE#2 EXT• BOS DISTRICT LOCATION CODE ( ) CONTRACTOR/ SERVICE REQUESTOR RERUESTOR` O I I /1 -ho _(A I„ D,� CHECK if BILLING ADDRESS BUSINESS NAME (VII X4/1►l (iV�'1A'1� 'r 1v11/�(,Q�l/� (� L�vI IL{� �1'J�E�/U Pc�1�E 1 '] 4 I; EXT. HOME or MAILING ADDRESS ` ZO F �p�A r. ^ AX# r CITY J 1 v r 1� I Vl �/�(, "� STATE /1/i ZIP 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. 1 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 FE ERAL laws. APPLICANT'S SIGNATURE: DATE: i Z S ZOZC� PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ If APPLICANT is not the BILLING PARTY proof of authorization to sign is required Tule 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, p TYPE OF SERVICE REQUESTED: � �� j/>�6V� : COMMENTS: , �V 1G� C �112b1 EC 1 2Q20 f0AQ IIV CDUNn, ACCEPTED BY: EMPLOYEE#: DATE: Z INV ASSIGNED TO: EMPLOYEE#: DATE: Date Service Completed (if already completed): SERVICE CODE: P I E: OZ, All Fee Amount: Ix 1 Amount Paid 4:t5o��/5a.--rpayment Date 2 1 e,/2-0 Payment Type Invoice# Check# Received By: EHE 48-02-025 SR FORM(Golden Rod) REVISED 11/17/2003