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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID# SERVICE REQUEST# T-Acio2-volts 132001�27nS OWNER/OPERATOR 1.^o 1aI cA Ml✓!1.sem/ CHECK If BILLING ADDRESS El FACILITY NAME f-I �1� U I I ( t/�I(r1r�•'n SITE ADDRESS 120 S Ca Street Nulmber DI ctlo treat Na a IY-NCIt ZI Code HOME or MAILING ADDRESS (If Different from Site Address) T1 r JVL�I Iv i_ n` Street Number t t Y I Street Name CITY /-)to , r STATE QA ZIP q f2-1 2- PHONE#1 APN# LAND USE APPLICATION# (201) (0l 9—') l qEXT ILI-I '73DDS PHONE R ExT• BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR WA V1 C`s C'0 Yl I I iM ,/t� /�l'S CHECK If BILLING ADDRESS BUSINESS NAME vl • PHONE# Exr. �� C�2u i IU N2ta S21d(/� _*3 ) HOME or MAILING ADDRESS 'J�r (AX# ) CITY �L1� 1 V STATE /1. ZIP gcyzo S 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, STATE and FE E�L law . APPLICANT'S SIGNATURE: 1 ./ 11 DATE: PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT 11 If APPLICANT is not the BILLING PARTY 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 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: fbo V61l cA 1} COMMENTS: �J AIN.q 3�d �k �VeD �u T?3 ?t7p0 JOAQUIN y t7.1�ON OU EPgRTT INTI' ACCEPTED BY: V IM EMPLOYEE M DATE: Q -13- 20 ASSIGNED TO: Y_ EMPLOYEE M DATE: Date Service Completed (if already completed): SERVICECODE: 00 PIE: 03 Fee Amount: c* 152, ()L7 I Amount Pai IS"a,C)D Payment Date G 2D Payment Type Invoice# Check# Received By: EHD 48-02-025 SR FORM(Golden Rod), REVISED 11/17/2003 /YC/7�