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SAN JOAQ*COUNTY ENVIRONMENTAL HEAL? APARTMENT SERVICE REQUEST Type of Business or Property (.lam( FACILITY ID # �f{(jpO2�O2 BUSINESS NAME Ro W SERVICE REQUEST #o-f-+mQn�s T-5 �LI O -Z / OWNER / OPERATOR ,,,,rrrr7777 CHECK if BILLING ADDRESS FACILITY NAME V I S3`7 - 1 6n SITE ADDRESS z., -'7 •3 StreetNumber L, -)S Direction `� W � t r U -('A Street Name City 2 Code HOME Or MAILING ADDRESS (If Different from Site Address) Street Number 9lMFN >3' Stmet Name CITY STATE ZIP PHONE#1 En. APN # - N om„ LAND USE APPLICATION # PHONE#2 Ex . BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REOUESTOR (.lam( CHECK If BILLING ADDRESS BUSINESS NAME Ro W PHONE# (209) EXT' 9'3-r- 65Oa HOME or MAILING ADDRESS 62 t Moisin ea- rd FAX# (zoo ) S3`7 - 1 6n CITY / e feS STATE C (1 ZIP 615-30-7 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 COUNTY Ordinance Codes, Standards, STATE and FED laws. APPLICANT'S SIGNATURE: �� DATE: 2 J ? PROPERTY/ BUSINESS OWNER❑ OP TOR / MANAGER" OTHER AUTHORIZED AGENT ❑ If APPL7CANTisnotthe B7LL7NGPAR7Y 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 environmentaUsite 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. #04 1,- TYPEOF SERVICE REQUESTED: (.lam( HF "'yF COMMENTS: Sq per 2 ``o HFg4104Q 9lMFN >3' ACCEPTED BY: - N om„ EMPLOYEE #: -2�G -7 o DATE: U 2� 3 ASSIGNED TO: vt OW Yt)`V EMPLOYEE#: 62 DATE: 23 t3 Date Service Completed (if already Competed): SERVICE CODE: S Z 2 P "E: 3 Z Fee Amount: -Z —' Amount Paid ��,� Payment Date Payment Type-- Invoice # Check # /s-%S� Received By EHD 48-02-025 SR FORM (Golden Rod) REVISED 11/17/2003