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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property i>M Q !r FACILITY IID # SERVICEREQUEST # luca Siva - SV VAa ACCEPTED BY: K p OWNER/ OPERATOR DATE: / FAX # � l l T R V&t_ / CA.) /LI YC CHECK If BILLING ADDRE55 FACT ITY NAME 3 Date Service Completed (if already completed: SERVICE CODE: L PIE: / Fee Amount:L4 1-7 �' SITE ADDRESS LA - SS ✓ j)(� ROTI'1 010.LAT1A(t.OP Payment Type �, "- 95slo Street NU Direction Street Name Cit ZipCode HOME Or MAILING ADDRESS (If Different from Site Address) 5 D Street Number Street Name CITY K"Jaxvtl.LR STATE ZIP `Tti '610101 PHONE #t (SbS) 414-W5 Exr. APN # Ioi3-'5U-V LAND USE APPLICATION # wl" PHONE #2 Ex . BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR i>M Q !r A iL.YLJ CHECK If BILLING ADDRESS Pf BUSINESS NAME PHONE # Exr' ACCEPTED BY: K HOME or MAILING ADDRESS DATE: / FAX # CITY 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: / 1� / ✓ DATE: ry PROPERTY / BUSINESS OWNERYJ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT ❑ 1fAPPLICANTis not the BILLlNGPARTY. 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. 7 TYPE OF SERVICE REQUESTED: i>M Q RFI'. MF'•/ COMMENTS: qIt 19 O �� Q ACCEPTED BY: EMPLOYEE #: DATE: / ASSIGNED TO: EMPLOYEE #: DATE: ' _ „ 1-7 Date Service Completed (if already completed: SERVICE CODE: PIE: / Fee Amount:L4 1-7 �' Amount Pai ✓ j)(� Payment Date Payment Type �, "- Invoice # Check # 32-1a--�-17 I Re eived By: EHD 48-02-025 REVISED 11/17/2003 SR FORM (Golden Rod)