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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID # SERVICE REQUEST # 00 SO-10 OWNER / OPERATOR CHECK if "}Oft) 041C , 0t(11 6 BILLING ADDRESS FACILITY NAME / 737313 Street Number Dire-ction SITE ADDRESS Street Name ct Y Zip ode HOME Or MAILING ADDRESS (If Different from Site Address) 17-3W Street Number AV6- Street Name CITY R/11)06( 6.NATATE ,.,11,i76 &.., PHONE #1 ExT. (2eq) e' APN # LAND USE APPLICATION # PHONE #2 EXT. BOS DISTRICT s- LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR en r_ /fits d c -1c:' i CHECK if BILLING AzygEss El 4 SAN JOAQ-07 BUSINESS NAME PHONE # ( ) 9 HOME or MAILING ADDRESS / 7,5g 7 S-. 6-G/G-i v 1 il FAX # evviRoN ccl H SALT,/ czniti ENri CITY /PON STATE ek 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, ST TE and EDERAL law J. APPLICANT'S SIGNATURE:- DATE: g/9 2O2 — PROPERTY / BUSINESS OWNER OPERATOR / MANAGER 0 OTHER AUTHORIZED AGENT 0 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 the same time it is provided to me or my representative. TYPE OF SERVICE REQUESTED: lif i ey Aut. .4e 1l on AP& a /4S"21'03g is rio ' brijer A eYei to pe 1 )11 COMMENTS: c 5 wet ) 41,101 yviee4 Se tboiGks /C> 'r ?Y 1,J/4.0 .e XecU 4- ive Dicier AJ-7-;. • ACCEPTED BY: ..---- Z.-- 2 EMPLOYEE #: DATE: 2:Ti/ q 2 ASSIGNED TO: A G EMPLOYEE #: DATE: jriil *3 Date Service Completed (if already completed): SERVICE CODE: 0 G 1 P / E: 1_13o; Fee Amount: * IS Amount Pai /56,0D Payment Date Payment Type diee_ j;--1, Invoice # Check # ) <-1-g-61-r7 235- Recei ed By://ft 4- 22 Any Ni- SR FORM (Golden Rod) EHD 48-02-025 REVISED 11/17/2003