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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property \ M BUSINESS NAME d ^ J FACILITY ID # SERVICE REQUEST # FT#V A ( ) /--32 70 CITY -:ra ( ml STATE O ZIP 61--3320 EMPLOYEE #: Si. DagS-2u Ll— OWNER/ OPERATOR �/� /Jl/ v CHECK If BILLING ADDRESS ❑ FACILITY NAME Date Service Completed (if already completed): SITE ADDRESS1 O dl S /Or �" C ___ Street Number Direction "� Str lTam�e Invoice # ity Zip Code HOME or MAILING ADDRESS (If Different from Site Address) Street Number Street Name CITY STATE ZIP PHONE #1ExT. (a�,) y� -o8�a APN # a,�gOFoa B LAND USE APPLICATION # H NE #j Ex. 00q) BOS DISTRICT 5- LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR CHECK If BILLING ADDRESS 't( (/ \ M BUSINESS NAME d ^ J PHONE # _ EXT. 7% /� ,�gs•� HOME Or MAILING ADDRESS - Y Ods -) al ell & J2c FT#V A ( ) /--32 70 CITY -:ra ( ml STATE O ZIP 61--3320 BILLING ACKNOWLEDGEMENT: 1, 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: �ij� C CJ e�{� DATE: �/2 9 PROPERTY/ BUSINESS OWNERO OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT ❑ !f APPLICANT is not the BILLING PART)' 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: �0) I -SO 1I Gt✓t d N flat+ c L-00 6 .Sf U dY Re V 1 e L✓ PAY COMMENTS:ECEiV SEP 29 2 SAN JOAQUIN CO ENVIRON ENT HEALTIi DEPINTAJ ACCEPTED BY: ��" �� EMPLOYEE #: DATE: 7/,0/,?;1 ASSIGNED TO: A6 EMPLOYEE #: DATE: Cl/d ef ,I Date Service Completed (if already completed): SERVICE CODE: P I E: a b v '� Fee Amount: f (-- a q Amount Paid ___ I Payment Date v l i,v Payment Type V /-/>V Invoice # C ck # /S -,n 6 l`5 J� Received By: EHD 48-02-025 SR FORM (Golden Rod) REVISED 11/17/2003 22 INTY J. ENT