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SAN JOAQUI*T "OUNTY ENVIRONMENTAL HEALT' DEPARTMENT SERVICE REQUEST Type of Business or Property Vick OCI FACILITY ID # -] 2lS�v SERVICE REQUEST # Weeo & e707-3 0 OWNER I OPERATOR f=� n 44� r � K— r G CHECK if BILLING ADDRESS FACILITY NAME t I gm SITE ADDRESS '/y�l�ygS2D7 Numbe/ Direction '�8heet Nam Clt !ZI Code '�H(OME Or MAILING ADDRESS (If Differentjrom Site Address) I0% Street Number Street Name TY S / Pt _i) ZIP q�?G I f J STATE ZIP PHONE #I EZT. APN # / p ^ LAND USE APPLICATION # PHONE#2 EXT. BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR C OCI CHECK if BILLING ADDRESS G Atm BUSINESS NAME ao So (AT-fC 15 PHONE# 201 EZT' 61•ovfZ HOME or MAILING ADDRESS FAX # `%'vt fr - Iorele ( > CITY !R 1,alI! STATE e ZIP q�?G I f J 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, STA)qand FEDERAL laws. APPLICANT'S SIGNATURE: ae4= DATE: t rZ, Ic PROPERTY/ BUSINESS OWNER 13 OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT 13 IfAPPLICANT is not the BILGING 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 environntental/site assessment information to the SAN JO.AQUIN COUNTY ENVIRONMENTAL HE LTH DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. iU�c c.iJ �L ion Yoe—Ti CP E-c� TYPE OF SERVICE REQUESTED: C VIA OCI PAYMENT COMMENTS: JUN 15 201 SAN OCOUNTY ENVVIRIRONNMM ENTAL HEALTH DEPARTMENT ACCEPTED BY: Lr;) C, ( u E I EMPLOYEE #: L/ DATE: ASSIGNED TO: EMPLOYEE #: DATE: Date Service Completed (if already completed): SERVICE CODE: PIE: 3llpO% Fee Amount: q 60 . CA-) Amount Paid I Payment Date �$ , Payment Type Invoice # Check # + Received By: rjZS EHD 48-02-025 SR FORM (Golden Rod) REVISED 11/17/2003