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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST 2 D5 U I Type of Business or Property FACILITY ID# SERVICE REQUEST# DU3q SRo�� D�o) OWNER/OPERATOR 1 (` `-L ^ V-A '�, 1�L �� CHECK If BILLING ADDRESS FACILITY YNNAMMEE"L.OV1Gt•�ER-� L-PvJR-1c1f SITE ADDRESS r1(211// C V' 5/�f'1//� Sheet IJUmbar Direction Cal I t//I,��Street Name � Cit n qZI Code HOME or MAILING ADDRESS (If Different from Site Address) 1-1155 S 1V-4 71t�M{pLc— S— Street Number Street Name CITY $TATE ZIP 5'rlx ND%J CRL• 1�3b PHONE#1 En' APN# LAND USE APPLICATION# (2t>9) GI as SS54 PHONE#2 Exr• BOS DISTRICT LOCATION CODE ( ) CONTRACTOR/ SERVICE REQUESTOR REQUESTOR l,–I4I7 `y/ A M1CAl,+C—` CHECK If BILLING ADDRESS BUSINESS NAME L�AI� I` ��•V PHONE# Ems. WtD x NG—(Z^ � HOME or MAILING ADDRESS FAX# I KS S N ti CITY Sto` ,4 o cfn,. �t�2O 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,STATE and FEDERAL laws. APPLICANT'S SIGNATURE: t I(ym MSL DATE: PROPERTY/BUSINESS OWNERI- OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ /fAPPL/CANT is not the B/LLINGPARTY proof of authorization to sign is required Tule 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. P TYPE OF SERVICE REQUESTED: W-61-It ConSu �n F l COMMENTS: 110 J f pwVr ►� �D f) ',44 10 Mg ACCEPTED BY: CRAM`,, EMPLOYEE#: T?I DATE: I� ASSIGNED TO: ax*k 10 EMPLOYEE#: 3 DATE: Z I Date Service Completed (if already completed): SERVICE CODE: O PIE: 37. Fee Amount ` 'G Amount Pai �S� bD Payment DateYZ 712-1 Payment Type Invoice# Check# Recei d By: EHO 48-02-025 SR FORM(Golden Rod) REVISED 11/17/2003