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P (Z (D523 `1 '01 SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID# SERVICE REQUEST# � s� 514 1 OWNER/OPERAT R ^7 1 �( J' 1/ `/'/ p /� �n� a/ C.�l/ v �A't�.Pt'1 CHECK If BILLING ADDRESS� FACIDTY NAME NCW XN81AN SvPEt2MAkK'Er SITE ADORrEESS$ N ' TkA W R�()4l -TP-AC y R S-3-76 325u Street Number I 111mctIm Street Nam ZIP Code HOME or MAILING ADDRESS (If Different from Site Address) Steal Number Street Nam CITY STATE ZIP PHONE#IAPN# LAND USE APPLICATION# (41)9) 644 4 PHONE#2 EST BOS DISTRICT LOCATION CODE ( o ) 2 - 2939 11 CONTRACTOR/ SERVICE REQUESTOR REQUESTOR n�1,4 yc E r SL,��A CHECK If BILUNG ADDRESS BUSINESS NAME J C.- ll �l PH ..It �T• AJE k) X-NDIAN SUPE-k-M k/CET � 414 4 � HOME or MAILING ADDRESS FAX# 32S-0 , 6A ( ) CITY t1 wA STATE LP 2j t-3 '7 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 application and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes,Standards,STE and ERAL laws. -2_PRAPPLICANT'S SIGNATURE: DATE: D 2'L I:�4 2.2- PROPERTY/ OPERTY/BUSINESS OWNERYC OPERATOR/MANAGER ❑ O"ITIER AUTHORIZED AGENT❑ If APPLICANT is not the BILLING PARTY proof of authorization to sign is required Title�P�AYMENT AUTHORIZATION TO RELEASE INFORMATION:When applicable, I, the owner or operator of the property-locCaRVaRe above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental!i Its' information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the Same time``1tYY provided to me or my representative. VAN JOAOUIN COUNTY ENVIRONMENTAL TYPE OF SERVICE REQUESTED: t� (j COMMENTS: S'` e:_ _ r"PIh.La�U.Qt�VPgfL�y-I. Y QC P f J /:- 4d C:_Q-(.,f &UJ-V-L� 27 /S CaLC�o/ k PAIJI PUH -g7ALL" ND PEAT 11-4 �j N© pc44,r err, g D-t L A Lew o-v'S,46VA" Ns-k &-�S I e ACCEPTED BY: EMPLOYEE M DATE: ASSIGNED TO: ,e EMPLOYEEM DATE: ,,^^ Date Service Completed (If already completed): SERVICE CODE: O b 1 P I E: Fee Amount: ` Amount Paid Payment Date —7 Payment Type J Invoice# Check# Received By: EHD 48-02-025 14 11 o�g`1 ( Z� —Z.o SR FORM(Golden Rod) REVISED 11/17/2003 S