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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID# SERVICE REQUEST# 'gSlfa- S"O 6/9Gr3 OWNER/OPERATOR CHECK If BILLING ADDRESS O FACILITY NAME Oil I SITE ADDRESS 1I�7(JI . //-}Y I cf y 96 Street Number Direction �✓'V h / I $Iraal Nam. 21 God HOME Or MAILING ADDRESS (If Different from Site Address) Street Number Street Name CITY STATE Zip PHONE#1 E.T. APN# LAND USE APPLICATION tt I I PHONE#2 EXT. BOS DISTRICT LOCATION CODE 1 1 ------------ CONTRACTOR/ SERVICE REQUESTOR REQUESTOR /J jz V I CHECK If BILLING ADDRESS BUSINESS NAME PH # VL / HOME Or MAILING ADDRESS ' / F y Cm 810- r ( ) �PL o SAL (kr' '14 STATE ZIP BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as identified on this form. I also certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes,Standards, STAT FEDERAL laws. APPLICANT'S SIGNATURE: DATE: �p�A�-C�y}O�I' t1HOYEKI'Vi BCSIRE$S OWNFR❑ OPERATOR/YIANACFR ❑ OTI RAU'rHORr7,EDACENT� Jr,rr(/ire�J� r n ® ijfAPPucnroTisn theB1wvGPARTY, Proof Ofauthorilationtosign isrequired Title 4C;aORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the siteaddress, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment <=Ration t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL.HEALTH DEPART'YArm as Soon as it is available and at the same time it is —rTyr d to me or my representative. SERVICE REQUESTED: POOL I/s� Ret Vie (,om�7 /fC�nG! on l o Comp + pCS/ P �a w l2e/' /41 . ND i .ACCEPTED BY: Z,pb t9 �.p� EtnPLOYEE#: �aod HATE: ! 31 11 ASSIGNED TO: L u 0 S v,C{cJ EMPLOYEE#: 2-13 DATE: Date Service Completed (if already completed): SERVICE CODE: I Jr2Z PIE: 3102 Fee Amount: O n Amount Paid Payment Date Payment Type invoice# ��X v Ckank# 23o.do g2g Received By: CYa EHD 48-02-025 GeL 4-k� lip\ 1 14 ` DID REVISED 11/17!2003 SR FORM(Golden Rod)