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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID # SERVICE REQUEST # 900i345/ I OWNER/ OPERATOR CMAN 14 Jo HA 51/sit-- CHECK if .5 9 BILLING ADDRESS FACILITY NAME 0 I i ye SITE ADDRESS Ill l mber S Direction 4 STD C---1-3/\) city 0 f C hiPAla. y q 3'1. ' Street N 44-1*---fagi 0 HOME Or MAILING ADDRESS (If Different from Site Address) 29 3?‘ rtowri ce-Tho p2 Street Number Street Name Cm, ,--• STATE eif ZIP 5- 02 c coy 9 -TDC-----1-0/\/ PHONE WI Ey. APN # LAND USE APPLICATION # i PHONE #2 Eta. ( ) BOS DISTRICT LOCATION CODE CONTRACTOR! SERVICE RE UESTOR REQUESTOR 4. _5 -------- C) EA S#W7I-i- i 644 SY:city CHECK if BILLING ADDRESS BUSINESS NAME __---- PHONE # fr1-67 ) C.):7 g „ EXT. 9 X ) HOME OP MAILING ADDRESS Dr- FAX # ( ) 9 3'/ frt own LEI-I-0 CITY ,..T.z,tprtvv STATE til• ZIP 9 cc)._ b 9 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, S TE an E aws. APPLICANT'S SIGNATURE: PROPERTY! BUSINESS OWNERS 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: 1 am i CArief 14- ladi yik, it A odolle COMMENTS: fovd , 414), , tri 84k/o,q,. 114417.VO?anN Co H 0 44 UN eP Sit iv ACCEPTED BY: LOC t/f tr0 5 • EMPLOYEE #: q4 30 ---0 DATE: 5 2 7.4 ASSIGNED TO: Kotefrcmor L. EMPLOYEE #: q TR-- DATE '' 5 / 2-119-/ Date Service Completed (if already completed): , SERVICE CODE: 5;2.3 NEVI) I Fee Amounti. n'op Amount Pai,/p 0./.5,. 00 Payment Date 3/27/2 j Payment Type V 136— Invoice # Received By: 47. Cht # 757572J'-) ') 2-iftP4;I=1 2C3 C 1ZPqs(4,11- SR FORM (Golden Rod) 9,0 9-1(9 991 5 OPERATOR! MANAGER OTHER AUTHORIZED AGENT 0 DATE: