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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property Irm CHECK if BILLING ADDRESS BUSINESS NAME ']�� r' , y^K. FACILITY ID # PH E# 3� ExT. SERVICE REQUEST # VAcAi\jr Lmo, 00ri) TgT— /(-19(? CITY *-IV STATE ZIP S17 STM pEP �NTgI OWNER/ OPERATOR ACCEPTED BY: L L `—A EMPLOYEE #: ` ASSIGNED TO: CHECK If BILLING ADDRESS FACILITY NAME Date Service Completed (if already completed): SERVICE CODE: P / E: a 19 03 SITE ADDRESS Amount Paid I 0A ou i+.,wi jfc `(�.1 �/ / M(�,�/l "I Payment Date i ME NT V Street Number Direction Street Name I Receiv elme Cit Zip Code HOME Or MAILI AD�SS (If Different fro Site AddressStreet Number Street Name CI STAT ZIP qnoy PHONE # j ExT• APN_# - r �O VY i LAND USE APPLICATION # �1! PHONE #2 ( ) ExT BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR Irm CHECK if BILLING ADDRESS BUSINESS NAME ']�� r' , y^K. CES PH E# 3� ExT. HOME or MAILING ADD SS O 00ri) TgT— /(-19(? CITY *-IV STATE ZIP S17 BILLING ACl-NOWLEDGENIENT: 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: DATE: PROPERTY/ BCSINESs ONNNE.R❑ PERATOR /MANAGER ❑ OTFIER ACTIIORIZED AGENT 1Z 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: 50 L Skofelce 111 1)G, rv^ I fi C1 0k, ke o r+ R COMMENTS: CES DSL, U 8•C� 1021 AQUR N1N COUNTY STM pEP �NTgI ACCEPTED BY: L L `—A EMPLOYEE #: DATE: IZ ASSIGNED TO: EMPLOYEE #: DATE: ' Z ¢ Z / Date Service Completed (if already completed): SERVICE CODE: P / E: a 19 03 Fee Amount: O L.l Amount Paid I Payment Date i ME NT Payment Type Invoice # Check # I Receiv elme EHD 48-02-025 REVISED 11/17/2003 Iia- ►2ec.d SH F73Rty�(�O�Mod) SAN JOAQUIN COUNTY ENVIRONHEALTH nI=aA'. L