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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type Gfmess or Property FACILITY ID # SERVICE REIJ EST # �s4a Sl ')fCtiA av PHONE # EXT. ao (010-yz15 SQ00� q55 OWNER IP RATO CHECK If BILLING ADDRESS O FACILITY NAME - ASSIGNEDTO: SITE ADDRESS}} Ii� (� T • T Date Service Complet d (if already completed): L Street Number Direction Amount Paid I Street Name ;It ZI Coda HOME or MAILING ADDRESS (If Different from Site Address) Invoice # Check # Street Number Street Name CITY STATE ZIP 5-1,0 G lJ PHONE #1 2_Exr. (ZOG) APN # LAND USE APPLICATION III PHONE EXT. /OO�NE#2 BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR CHECK if BILLING ADDRESS El BUSINESS NAME �Uu6dj COMMENTS: PHONE # EXT. ao (010-yz15 HOME or MAILING ADDRESS \ I 1'1' ACCEPTED BY: - ilA) CITY STATE ZIP o 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 DEPART ENT 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 aliclication trid that th . ork to b erforme 'Il be done in accordance with all SAN JOAQUIN' COUNTY Ordinance Codes, Standard., S ATE and EDE& 1 .t APPLICANT'S SIGNATURE: Alk 11 1 subRim DATE: 2 Z PROPERTY / BUSINESS OWNER❑ IfAPPL/CANTLs not the OTHER AUTHORIZED AGENT ❑ 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 assessmcnt4 information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as Soon as it is available and at the ne it is provided to me or my representative. iQ�; eAl-s- TYPE OF SERVICE REQUESTED:M (-f7 Q. �/7 4J �11 COMMENTS: Q y44111All �ipFAafNrk �I' �l ACCEPTED BY: EMPLOYEE#: Zia DATE: 3 22 ASSIGNEDTO: EMPLOYEE#:) DATE: �L Date Service Complet d (if already completed): SERVICE CODE: �2 3 P 1 : •i`o I Fee Amount: 6 -, Amount Paid I Z4 / Payment Date a Payment Types Invoice # Check # Received By: EHD 48-02-025 REVISED 11/17/2003 Mi SR FORM (Golden Rad)