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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 011 a' DO SERVICE REQUEST Type of Business or Property CHECK If BILLING ADDRESS® FACILITY ID # SERVICE REQUEST # Re -SI -depict PH ) # _ Exr. HOME: or MAILING ADDRESSI C. oa FAx # ) �/ CITY C 1 n �1 l OWNER/ OPERATOR 10 Haurl-yt O CHECK if BILLING ADDRESS ® L C) Date Service Completed (if already completed): FACILITY NAME SERVICE CODE: v SITE ADDRESS Qty!1 Fee Amount: / S 2 dole Dn v�, /� C v S-��Ktan 61521 Z Street Number Direction Street Name Check # CII HOME or MAILING ADDRESS (If Different from Site Address) �E Street Number Street Name C / CITY STATE zip MAY PHONE #1 E'er. APN # LAND USE APPLICATION # Sq N ( ) S 13 O Z 3 J Oq QU H 4V/R0fVIN1 J: R N IN C l PHONE #2 ExT. BOS DISTRICT LOCATION AIR ] CONTRACTOR / SF,RVICF. RFnITF.CTnR REQUESTOR Robert '(rI D � CHECK If BILLING ADDRESS® BUSINESS NAME ' vv � 9 I U m Wn Y�Puy(. P09CI'61 c-racl.� PH ) # _ Exr. HOME: or MAILING ADDRESSI C. oa FAx # ) �/ CITY C 1 n �1 l STATE ZIP q r(I 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. 1 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: DATE: 0s —1q-202( PROPERTY / BUSINESS OWNER[] OPERATOR /MANAGER ❑ OTHER AUTHORIZED AGENT ❑ �.i/�11 GI.0-��/ 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: COMMENTS: Sj`-� QvaWcthiOvl FbV Y�Puy(. P09CI'61 c-racl.� Fi'clds f P� ACCEPTED BY: EMPLOYEE#: DATE: / J ASSIGNED TO: Q� P� EMPLOYEE #:ot rl f— DATE:_57 Ila/ 1p Date Service Completed (if already completed): SERVICE CODE: v P / : Fee Amount: / S 2 Amount Paid.: /� C v Payment Date Payment Type, Invoice # Check # Received By: EHD 46-02-025 REVISED 11/17/2003 SR FORM (Golden Rod) ./V T ,ED 2 1NTy L cNT