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SAN JOAQUL -OUNTY ENVIRONMENTAL HEALTH . ;PARTMENT SERVICE REQUEST P R C) 95-� 1 Type of Business or PropertyFACILITY ID# SERVICE REQUEST# IU47q FskoV-'q0q__. O NER/OPERATOR (` Q.✓•1 C' Qrrc' c{–• cel Zc QjA CHECK If BILLING ADDRESS FACILITY NAME a I cc.Ci �-� 1c� vert' � $ITE ADDRESS 1 'r,- [ 80Y7waO �- sut�C 5'� C T�h ?S o.qo 2 Street Number Dlrection Street Name Cit ZI Code HOME Or MAILING ADDRESS (If Different from Site Address) /, 6 coY-Y'0 V t Street Number S 0 C6 r'��a Street Name A ve CITY STATE ZIP - :5 AA vc. e c� quo Fl PHONE#t ExT• APN# LAND USE APPLICATION# (65o) 17 a2, - PHONE#2 Exr• BOS DISTRICT LOCATION CODE c ) 50 Ll- $o CONTRACTOR/ SERVICE REQUESTOR REQUESTOR Mart s. J ,p,-c AD C.fc.et ZepcdS CHECK if BILLING ADDRESS BUSINESS NAMEPHONE# EZT. a Gi IF c� �erlr 0. a ) HOME Or MAILING ADDRESS FAX If 115q 50 CO T"YYo '& ( ) CITY U n h v c- C STATE C'& ZIP 01 L-to 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:Looe, ti M erc-.An DATE: O4 - � � PROPERTY/BUSINESS OWNER 2' OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ If APPLICANT is not the BILLING PARTY proof of authorization to sign is required Title AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, 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�t the same time it is provided to me or my representative. A� TYPE OF SERVICE REQUESTED: COMMENTS: Jut SAIyJ202 f/y DAQUi HEA[.M�FPM�O�N)Y ACCEPTED BY: C EMPLOYEE#: v DATE: 15 "1-/ASSIGNED TO: 'C V— `J EMPLOYEE#: 2 DATE: /JL IA Date Service Completed (if already completed): SERVICE CODE: v I PIE: Fee Amount " 011 Amount Paid r 'f Payment Date -1 2 vV Payment Type C Invoice# -f2/# �L�-I Received By: EHD 48-02-025 ` SR FORM(Golden Rod) REVISED 11/17/2003