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SAN JOAQUIP. —OUNTY ENVIRONMENTAL HEALTH —PARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID # SERVICE REQUEST # OWNER / OPERATOR D..4A %-•D RoCr E(.) CHECK if BILLING ADDRESS FACILITY NAME 17^ /Ns to% I'S 5 an sT SITE ADDRESS 5) $ Street Number it,1 1 i Direction cl -wsr T IL/- WA-1 Street Name STPCY40A City 9 5 ZO /0 Zip Code HOME Or MAILING ADDRESS (If Different from Site Adess) I VI 00 S. VA 140 n 14Q40 Street Number Street Name CITY , M., N 'T ZcPT sew ZIP IS 33 1 PHONE #1 Err. (ab tk ) 1'O ki ''' 5 7 b— 0 APN # 14 11— 0 -7`i —4z) 01.31 LAND USE APPLICATION # PHONE #2 EXT. ( ) ' BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR ---1,:;" GI VIA,/ CHECK if BILLING ADDRESS Er BUSINESS NAME A _, V VA rt. to tline."%i•ir 0 AMedNitk ) # IfNk. PHONE # ( Lti ) EXT. 4 101- I Do ko HOME or MAILING ADDRESS i7 5Ai f ag. 0 A-4() FAX # ( ) CITY 5/.. c r rciAJ tfA STATE eel ZIP cire BILLING ACKNOWLEDGEMENT: ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or project specific ENVIRONMENTAL HEALTI-I 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, ST ATE and FEDERAL laws. • APPLICANT'S SIGNATURE: .01PAtib6.7 ER DATE: 02.-4ZI — 2_ck le PROPERTY / BUSINESS OWNER El OPERATOR / MANA pg. OTHER AUTHORIZED AGENT 0 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: COMMENTS: ACCEPTED BY: EMPLOYEE #: DATE: ASSIGNED TO: EMPLOYEE #: DATE: Date Service Completed (if already completed): SERVICE CODE: P I E: Fee Amount: Amount Paid Payment Date Payment Type Invoice # Check # Received By: EHD 48-02-025 SR FORM (Golden Rod) REVISED 11/17/2003