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L la OPERATOR / MANAGER 0 CDATEr"^1 OTHER AUTHORIZED AGENT I-I COUNTY Ordinance Codes, Standards, STATE and F APPLICANT'S SIGNATURE: PROPERTY / BUSINESS OWNER 0 1- 1-9-eQ-e) SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID # SERVICE REQUEST # SC-010 g V2-12-- rOwNER /10PEkATOR, 5\-qA,\CA g KV.0-4,,, CHECK if BILLING ADDRESS -Ram NAME) Dv, e, Six' p s f \ N o )c<0. r .9re sITE ADDRESS GS c).___5"- pc_ -rrellACArcbStrecrIbmber Direction Street Name 563% e-doogi- \ City y5c9-05-- Zip Code A-10ME Or MAILING ADDRESS (If Different from Site Address) ...--- Street Number Street Name - C52° r STATE C ZIP_ 0 L'OP6- 1 95010 S- 5±-o C --1:0\e, EXT. (PHONE # -40 q 3.4 APN # LAND USE APPLICATION # PHONE #2 Err. ( ) BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR -REQUESTOR3 SIrN0A- 4,t1, j2. ICIA-frk/t/ \ CHECK if BILLING ADDRESS BUSINESS NAME ---Pa 0 h f, Sly, p s morr_ie c4 (.01)-tia_14-iit PHONt A - k ,• Fug ( 1 EXT. HOME or MAILING ADDRESS ' - - - - g 30 5 ' rA°A"±3/'-67± fb1) fC> City " ts.„--.... 1-n AA Q. 9-(9 STATE ZIP 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 If 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 att.ststy time it is provided to me or my representative. PAYmt RECEIV CV TYPE OF SERVICE REQUESTED: '.....00 d 0 DASIA.A.k A-AVG \-"‘"-- COMMENTS: JAN 07 202I SAN JOAQUIN COUNTY HEALTH DEPARTMENTENVIRONMENTAL ACCEPTED BY: \I . yvvmoivo EMPLOYEE #: DATE: ASSIGNED TO: \i , Arn,..0 EMPLOYEE #: DATE: Date Service Completed (if already completed): SERVICE CODE: tlQ \ • Fee Amount: # \ C,2,2 . oa Amount Paid 4 / c 2 _- P/7 1002. Payment Date / Payment Type e_ Invoice # Check # Received By: EHD 48-02-025 SR FORM (Golden Rod) REVISED 11/17/2003