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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property S W) M j"J i, Pool J�, FACILITY ID # SERVICE REQUEST # LNZ? OWNER /OPERATOR V/ /% �/ V ( / A v l C HOME Or MAILING ADDRESS 9YI2��L_r 0 Ls)ik FAX/1#120_'�o ( ) CHECK If BILLING ADDRESS FACILITY NAME �! /9 ? +1 C sysfFrM F'� i OJc�rftrli' LF )nS rt?�� C�Itl1ur Hac:�Cr C.� ftr:�I%�`l}i lo(' -i0., C,('�(;l,fr.", Fw- CCEPTED BY:J / L� t, SITE ADDRESS / . (�(_� EMPLOYEE #: 11-one- ` EMPLOYEE #: DATE:4P/ Date Service Completed (ifalready completed): rJ-GJe Di ion Strl�Name Fee Amount: 5 Amount Paid 45;? 60 Payment Date HOME Or MAILING ADDRESS (If Dlffar—f f,-- cite AA- i r ^q EStLa eoad CITY PHONE #1 E -T, ON) � 02 - � 5 2 APN # 0 �3 � , LAND USE APPLICATION # _� A10V PHONE #2 ExT. ( ) BOS DISTRICT 11 /LfHQI�I CODE 41, F CONTRACTOR / SERVICE REOUESTOR ,,A(7- /86 r/86 921 rH oEpq�^'rfa�NrY EIV REQUESTOR e1c6 (moi ; n ,O/ ( CHECK If BILLING ADDRESS BUSINESS NAME ' D l ` /�j n PHONE^ ^ E>R• l CC__ HOME Or MAILING ADDRESS 9YI2��L_r 0 Ls)ik FAX/1#120_'�o ( ) - CITY STATE ZIP 0 BILLING ACKNOWLEDGEMENT: 1, 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- an EDERAL laws. APPLICANT'S SIGNATURE: -,t DATE: PROPERTY / BUSINESS OWNER❑ OPERATOR / MANAGER ❑ OTHER A THORIZED AGENT�LIY �% !✓ If APPLIC.4NT is not the BILLING PARTY proof of authorization to sign is required Titre AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, 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: �� tt �j //i �.qi') (, t'' �^ J i P� � O � � I ?-I r l�Y� (�CiG� sysf r'M (o r 'I >>^ l�; ►,l �t clf 4 C I S),S1e"" "tis r1ot leen t� 1 ®T i 'Fro. icAPE�• G.,� 1 rLw� f �'r.•�f, 1•�' ., ✓ Dias/ F 1' a. loCt� orJ,.t'. /PSP 61 �i>Z�6jj f r[ ? +1 C sysfFrM F'� i OJc�rftrli' LF )nS rt?�� C�Itl1ur Hac:�Cr C.� ftr:�I%�`l}i lo(' -i0., C,('�(;l,fr.", Fw- CCEPTED BY:J / L� t, EMPLOYEE #: DATE: I i �j i )I ASSIGNED TO: �� EMPLOYEE #: DATE:4P/ Date Service Completed (ifalready completed): SERVICE CODE: O (� L �J Fee Amount: 5 Amount Paid 45;? 60 Payment Date Payment Type t Invoice # Check # 3 / _ Received By: EHD 48-02-025 (_ ��.� iPS SR FORM (Golden Rod REVISED 11/17/2003 YCC4 C- ctGld %f ;2A I)A i x I