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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or PropertyFACILITY ~ ID # PHONE # Err. HOME or MAILING ADDRESS SERVICE REQUEST # CITY STATE ZIP 01Nr)cm � S 00� rw1 p OWNER I OPERATOR PYuSG A ACCEPTED BY: �� EMPLOYEE #: CHECK if BILLING ADDRESS uV1 ASSIGNED TO: lily 11C.J EMPLOYEE#: l fl DATE: 1 FACILITY NAME vt1-kec1,-}- 4 -Vt^dian Lt.✓ Date Service Completed (if already completed): SITE ADDRESS SERVICE CODE: /-1 E 4C1vNy+e✓ Lvi J1 6hxAu-D�l -A5Z10 12 1,45 Street Numbor Direction 1011512-2- Street Name Payment Type city Zip Code HOME Or MAILING ADDRESS (If Different from Site Address) �eoVt Street Number 1 (e.0voi V' Street Name CITY S CACV e i , o STATE ZIP CA PHONE #1 Err. APN # LAND USE APPLICATION # (ASS) 32ct - `1365 PHONE #2 Exr. ( ) BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR CHECK If BILLING ADDRESS BUSINESS NAME CiLIV�e- PHONE # Err. HOME or MAILING ADDRESS FAx# CITY STATE ZIP 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 and FEDERAL laws. APPLICANT'S SIGNATURE: k ,� DATE: 113 1-7 2- PROPERTY/ BUSINESS. OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT 13 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 dip same time it is provided to me or my representative. AY TYPE OF SERVICE REQUESTED: we, `ryr COMMENTS: CT � ACCEPTED BY: �� EMPLOYEE #: DATE: L/ 12'y2 ASSIGNED TO: lily 11C.J EMPLOYEE#: l fl DATE: 1 2� Date Service Completed (if already completed): SERVICE CODE: /-1 PIE: (p02 - Fee Amount: Amount Paid lPayment r Date 1011512-2- 2 Payment Type Invoice #@tte�1Z 5' I Received By: EHD 48-02-025 REVISED 11/17/2003 ��o�zcKn SR FORM (Golden Rod)