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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property FACILrrY ID #SERVICE REQUEST # R 5 " 3 4-lu 1 c.e�-i -.G -: � � � 0 00 OWNER I OPERATOR CHECK NBILLING ADDRESS BUSINESS NAME FAc Lm NAME SITE ADDRESS HOME or MAILING ADORE S N��gQUI hEALry pF -7-7Y,�� Y �J•) 3 C�• .C3 S Street Number Dlreetivn re Nam CI Zip Coda HOME Or MAILING ADDRESS (If Different from Site Address) - EMPLOYEE #: (1" Z3 Street Number Street Name CITY STATE ZIP PHONE#1 Er. 1 ) APN # LAND USE APPLICATION # PHONE #2 Ems• P 1 E: D SOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR /� CHECK I}BILLING ADDRESS COMMENTS: \ C' � '.�;"�, �,n\-�SI\6L � iC-� BUSINESS NAME -. VSo 1r41 -C. j c 14 , �.� L._L L. PHONE # Em. , IG Z 4 - Li S-0 HOME or MAILING ADORE S N��gQUI hEALry pF FAX# QRTM LNr CITY I C STA ATE ZIP q+ S .3 G t BILLING AlCICNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or project specific ENVIRONMEYCAL 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'�EDERAL laws. 7 APPLICANT'S SIGNATURE: DATE: ^ /[ PROPERTY/ BUSINESS OWNER❑ 6PERATOR/MANAGER OTHER AUTHORIZED AGENT❑ IfAPPL/CMT is no! the BTLLLRG 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 andtor environmentaUsite assessment information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at,the same time tt is provided to me or my representative. Q Y TYPE OF SERVICE REQUESTED: Cc/ COMMENTS: C�,tl Sq ? 20Z2 N��gQUI hEALry pF QRTM LNr ACCEPTED BY: - EMPLOYEE #: (1" Z3 DATE: C7 ASSIGNED TO: ��„L,p..N EMPLOYEE #: DATE: / 7- 2— Date Date Service COTPleted (If already Completed): SERVICE CODE: 'a P 1 E: D Fee Amount: t 1;�_Amount Paid 111,S2,66 Payment Date V131-2-9 Payment Type �Invoice # Check # ' Ssb Receive By: EHD 48-02-025 REVISED 11/17/2003 SR FORM (Golden Rod{