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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property yt/lJr1J DHECK It BILLING ADDRESS FACILITY ID # SERVICE REQUEST # PHONE# EM• a 12—lc�y� HOMEor nGrA-DDRESS Cj� ,.1 q FAX# �v rA✓ � OWNER/ OP RATOR ^ Y ` Cblo1 � l CHECK If BILLING ADDRESS FACILITY NAME LL-5Quelrr-'s ?G e,y G -,g (if air completed)' SITE ADORES S YI I I SERVICE CODE: C' 1 ,1/InI _ IM10 �^21//Cotle �J��/.�{�j /}�rl O Street Number Direction V41 ' Street Name Payment Date HOME or MAILING ADDRESS (If Different f om Site Address) C� Check # 71?' Sma.1 Number Street Name CITY (I — �cJvllY� i STATE ZIP PHOONE#1 BR. APN # LAND USE APPLICATION # (ZM) 2-1 PHONE#2 ( I ExT• BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR VIh.r yt/lJr1J DHECK It BILLING ADDRESS BUSINESS NAME' -/^ ^ t� Qv�Vr� V�r� PHONE# EM• a 12—lc�y� HOMEor nGrA-DDRESS Cj� ,.1 q FAX# CITY 1 jI r STATE / ZIP ( S'Z-. t T, 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, STATE an • EDERAL laws. ��//%% APPLICANT'S SIGNATURE: C:�/h-r DATE: PROPERTY/ BUSINESS OWN093 OPERATOR/ M GER ❑ OTHER AUTHORIZED AGENT If APPLICANT is not the BILLING PARTY proof of authorilation 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. PdV. _ TYPE OF SERVICE REQUESTED: COMMENTS: , 04(11-v `FVA&4,�5 Ma rv-` ACCEPTED BY; lA !'r L� EMPLOYEE #: t -I x��/••• 1 ) ,1V7 DATE: ",M U ASSIGNED TO: ,� () EMPLOYEE #: DATE: ?G Date Service Completed (if air completed)' SERVICE CODE: P I : Fee Amount: _ i5 Amo nt Paid/S� vD Payment Date / Payment Type (-/jam I I Check # Received By EHD 48-02-025 REVISED 11/17/2003 SR FORM (Golden Rod)