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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH Dt,PARTMENT SERVICE REQUEST rn2 1 284 . Type of Business or Property CHECK if BILLING ADDRESS ❑ FACILITY ID # REQUEST # BUSINESS NAME �� k® SAA1 jo 0 6 2a22 Bly QU/ HE,q� do f Cn °r(J 7'' PHONE# EXT. /SERVICE SK OaS3VIL4 IW s (ao - s HOME or MAIL I ADDRESS OWNER / OPERATOR Er y7'E , CHECK If BILLING ADDRESS FACILITY NAME STATE ZIP SITE ADDRESS ,34ae /X/ CyE9k11-AA0 A ✓EiVGfT STnf*q-ON g5 -a1, Street Number Direction Street Name Ci Zip Cod HOME or MAILING ADDRESS (If Different from Site Address) P0 . O x Street Number Street Name CITY k C7 STAT�F^ ZIP / 'gG PHONE#1 EXT. APN # LAND USE APPLICATION # 734 d zoo - t64 PA.;7-1 o a PHONE#2 EXT• ( ) BOS DISTRICTLOCATION C q1_1 J CONTRACTOR / SERVICE REOUESTOR REQUESTOR CHECK if BILLING ADDRESS ❑ COMMENTS: BUSINESS NAME �� k® SAA1 jo 0 6 2a22 Bly QU/ HE,q� do f Cn °r(J 7'' PHONE# EXT. EMPLOYEE (ao - s HOME or MAIL I ADDRESS FAX# _ o Date Service Completed (if already completed): ( ) 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 app ' n andth work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, Standards, T and FE RA ws. kv A- -&f/ A6 APPLICANT'S SIGNATURE:DATE: 06'a 'gPROPERTY / BUSINESS OWNER El OPERATOR /ANAGER ❑O HER AUTHORIZED AGENT If APPLICANT is not the BILLING PARTY, proof of auth ization 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. 1% TYPE OF SERVICE REQUESTED: SS�/G I�I 1=F COMMENTS: �� k® SAA1 jo 0 6 2a22 Bly QU/ HE,q� do f Cn °r(J 7'' ACCEPTED BY: ��J L lj EMPLOYEE DATE: 6 6 as ASSIGNED TO: k EMPLOYEE #: DATE: G 6 as Date Service Completed (if already completed): I SERVICE CODE: SOZ 3 P / E: a 6da Fee Amount: + 6 a � Amount Paid I 41 r0/�('�l Payment Date (VOR / 0 Payment Type r ,�p/ VY lJ� Invoice # Rfeceived�By: U&17� EHD 48-02-025 SR FORM (Golden Rod) REVISED 11/17/2003