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(NQ^W ' SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1 1� SERVICE REQUEST T pe of Business or Property FACILITY ID# SERVICE REQUEST# I stuVV14ntOf-TR uck ) _ SR008I�-y OWNER 10 TOR CHECK If BILLING ADDRESS S Y CDff�C0M FACILITY NAMEuym cf k SITE ADDRESS —1yo�`� W �Y�•(`f'�� }��ryf�/L'}t rl gSZ�(,P sheer mbar Dirort{a. SlreelN 1 Cv� Zi Coda HOME or MAILING ADDRESS (If Different from Site Address) \�0 I U-4rt(� JL Y k p y5{ I p C(t U street Namber F�111 It V`MstWree(Natm7eu CITY ("o/'A STAT ZIPilc�1, PHONE#I l.•��//�� APN# LAND USE APPLICATION# We) 31`6 -15 5 13 23 0� PHONE#2 Ear. BOS DISTRICTw LOCATION CODE I I CONTRACTOR/ SERVICE REQUESTOR REOUESTOR -r��o r Coar(oh0 CHECK if BILLING ADDRESS❑ BONINESS NAME Ch Wic `, }I,�rvinl ng odol & PH O# �/� ry�r�(1 E'R HOME or MAILING ADDRESS� 11) (AVtpf/`Y Vt/tIZJ (Ax# I Q bL V CITY 1 t'e OtYt STATE CAA ZIP 10 S70 BILLING ACKNOWLEDGEMENT: 1, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or project specific ENVIRONMEN'T'AL 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,STAT d FEDERA S. APPLICANT'S SIGNATURE: i DATE: O2 �✓ � �" PROPERTY/BUSINESS OWNER❑ OERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT YU IfAPPLICANT is not the BILLINU PART) 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 sante time it is provided to me or my representative. TYPE OF SERVICE REQUESTED: tx - I In `A-ec R C-N COMMENTS: L�L� AED JOA420 QuI 4 H 'DBP ZNT IY ACCEPTED BY: `ctv f-.�, iY LC EMPLOYEE#: DATE: ASSIGNED TO: L^ (moi Y.e r, EMPLOYEE#: DATE: 2—I 3_•YO Date Service Completed (if already completed): SERVICE CODE: Z PIE: , O� Fee Amount: ge+ 0-b I Amount Paid Payment Date Payment Type 'SQ Invoice# �p /� Check# Received By: 112,l U2 ' EHD 48-02-025 C �� I C)S' 1T / '"I d y SR FORM(Golden Rod) REVISED 11/17/2OD3 F ria 1 �S 5