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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID # SERVICE REQUEST # S ()Og S5)-8' OWNER / OPERA TORS'cf4 1-ot /den M0 10 1 1-101'1e Poi f k L L ( CHECK if BILLING ADDRESS FACILITY NAME Be ) 4 o Mob) 'r- 1 I I le E s I-6de SITE ADDRS8-- 7 j"-- Street Number Direction Street Name City Zip Code HOME Of MAILING ADDRESS (If Different from Site Address) G()S.- kr1166iC60€ to Dr. Ste C Street Number Street Name CITY STATE , C il ZIP PHONE #1 EXT. ( ) APN # LAND USE APPLICATION # 0871?)01-( 5-- PHONE #2 Err. BOS DISTRICT LOCATION CODE C7/ CI CONTRACTOR / SERVICE RE UESTOR REQUESTOR / T-1(i I; ^(_ _ CHECK if BILLING ADDRESS IN BUSINESS NAME , , ' V6 LI 4/t,7 .-<-..) r-1--' PHoNE# ( 2 ,-)41 ) 1-7 ) "— v.)-3 i EXT. HOME or MA(.ING ADDRESS FAX # ( ) CITY '''.2 7Z.,/e.; •I..,, 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 COUNTY Ordinance Codes, Standards, STATE and FEDERAL laws. APPLICANT'S SIGNATURE: DATE: e-1,/ ? PROPERTY / BUSINESS OWNER El OPERATOR / MANAGER 0 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: ; fe ci sSesyvierl f - rer re f;) i' y s +0 51/ch,y0 oki u n 11S S 1d (oi-I COMMENTS: fropoSed Os t4 A 00 legch WeS )-, V 711/S 63 lila G C 4-nd oi/SP Gr- core r i.- pris. po f i..i.an itiC yaob iIe hprvbe pr 14' ir,s oh 1. y wi lls.) fr i opt) ;17; ) 1/7 tf cDnneckni sciid ciiiiis" Jo neofreneni• 5,5 7Ler"- Ty i7A ve v,i ) 51 1 5 ec io vi pi 11E1 elle/hilt/0011 4 C ti eci t Wier/4 < ycif /1/, 4Ply 0 8 4 ACCEPTED BY:•••••••''',7"....- Z.--/...,-- EMPLOYEE #: DATE: 1.1/441 Q „ ASSIGNED TO: DA EMPLOYEE #: DATE: L..i y 7fie?E'PATD..417-Ale ,True Date Service Completed (if already completed): SERVICE CODE: 0C., i PIE: Li 420d Fee Amount: lEIS-, 0 Amount Paid Ii.:_-, a _ .-.7 Payment Date 11 Payment Type (V4.41_, Invoice # Check # tb.1-1, Receiveday. • t'/UY17( t-/ EHD 48-02-025 REVISED 11/17/2003 SR FORM (Golden Rod)