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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property BUSINESS NAMEPHON �M D ��N �M<. FACILITY ID # SERVICE REQUEST # ---FuP;L.1L oo CITY $TATE zip 9,Z2 2 A Poo 323/ 2 I (AZO OWNER / OPERATOR rI C I�r— 1W CHECK If BILLING ADDRESS LJ FACI ITY NAME W� e SITE ADDRESS p a J ` w �•- LD � � y _� DATE: ( Z� r /J St\reef Number Direction � Streef Name G,N �� HOME Or MAILING ADDRESS (If Different from Site Address) 27 SERVIan Gt V1 G 4 2E /T Amount Paid Slreetllumber /Zg / 1�Payment SlreetName CITY $TA� ZIP PH NE#7 / Ext. c _— �_Z APN # A C> t? LAND USE APPLICATION IV PHONE i2 EKT W BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR ``)` cv..� CHECK if BILLING ADDRESS BUSINESS NAMEPHON �M D ��N �M<. # I.T. � -.26'e.1-CA" HOME or MAILING AD RES$ FAX# Wt- TO 1!` 0 CITY $TATE zip 9,Z2 2 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 opRQlication and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, Standards, STARE and -FEDERAL laws. APPLICANT'S SIGNATURE: PROPERTY/ BUSINESS OWNER ❑ If APPLICANT Is not r-� DATE: urJ (/�.r �O. 00a MANAGER Q OTHER AUTHORIZED AGENT 6;-V,Ss rF proof of authorization to sign is required Title AU INUNICA I IUN 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 ti Imo- p✓'tjr ed to me or my representative. PA NT TYPE OF SERVICE REgUESTED; �> l ,{ VVt-6 �� p COMMEN IS; '1 ri lL SAN JOAQUIN COUNTY ENVIROMENTAL HEALTH DEPART MENT ACCEPTED BY: t. EMPLOYEE DATE: ( Z� r /J ASSIGNED TOT EMPLOYEE #: DATE: Date Service Completed (if already completed): SERVIan P/E:Fee Amount: 26o �.� Amount Paid /Zg / 1�Payment Type 1 Invoice # Check 4eceived By: EHD 48 02-025 07/17/03 SR FORM(GGl;len Rob)