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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID# SERVICE REQUEST# C;(�-r,-\ e- S(200833 OW'`1ER/\OPERATORJl 1 1 � � 5o`s CHECK If BILLING ADDRESS❑ FACILITY NAME � t/L�dVIQt'c�\ 1CcC 1� SITEADDRESS )l�/lv /A L,c)' X75 Zy U Street Number I Direction Street Name City Zi Code HOME or MAILING ADDRESS (if Different from Site Address) CPPi(f�) (-:> Street Number Street Name CITY STATE ZIP L, a ' G/�Z % zYl-A9a6 PHONE#1 ExT• APN# LAND USE APPLICATION# (,�O) 3 3q-RL k 3 O� 1 0:0 ?Iv PHONE#2 ExT• BOS DISTRICT ,.I LOCATION CODF/� CONTRACTOR / SERVICE REQUESTOR REQUES OR I \4 CHECK If BILLING ADDRESS BUSINES AMEKy" Me PHON _ / 2 ExT. HOME or MAILING ADDRESS FAX# CITY LD� STATE ZIP l-5'2 Yl-1j>oL% 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 fon-n. 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, STATESTATE d�ED RAL lawsRAL laws. APPLICANT'S SIGNATURE: DATE: g / PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER Lq OTHER AUTHORIZED AGENT❑ 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 at the same time it is provided to me or my representative. / �� TYPE OF SERVICE REQUESTED: 5.,t I SU: �u v I I� f G 12 CJ D` + I4,1 e [-O��(JI i 11 S J, kE-V/LQK0AYM COMMENTS: RQ 1 V "f V iUt Ph?Gt I G Yt 3/��a J RECE C 139S/ MAR 0 8 2 21 SAN JOAQUIN CO NTY ENVIRONMEN L HEALTH DEPART ENT ACCEPTED BY: / / EMPLOYEE#: DATE: 3 Q a ASSIGNED TO: ^/A EMPLOYEE#: DATE: 8 Date Service Completed (if already completed): SERVICE CODE:$a,I PIE. �,pa Fee Amount: (DY Amount Paid p _ Payment Date 24 1 Payment Type Invoice# Check# 13 I Received y: EHD 48-02-025 SR FORM(Golden Rod) REVISED 11/17/2003