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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID # Cesar Palacios SERVICE REQUEST # Residential PHONE# EXT• 5 R OO S 5 S 4 S OWNER/ OPERATOR 209 334-6613 Fernanado Salinas CHECK If BILLING ADDRESS FACILITY NAME PO Box 2180 N/A ( 209 ) 334-0723 SITE ADDRESS 4747 E. I Acampo Road Payment Date 3,6 ZZ Acampo 95220 Street Number Direction Street Name Ci Zi Code HOME or MAILING ADDRESS (If Different from Site Address) Street Number Street Name CITY STATE ZIP PHONE #1 EXT. APN # LAND USE APPLICATION # (209 ) 200-2990 1017-030-30 PHONE #2 EXT, BOS DISTRICT y LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR A)Yjr'-4e L".dirl %zev�t°ti✓ R N Cesar Palacios CHECK If BILLINGADDRESSE] BUSINESS NAME PHONE# EXT• DATE: 3a ASSIGNED TO: F 1Q 209 334-6613 HOME or MAILING ADDRESS DATE: FAX # PO Box 2180 SERVICE CODE: S,� 3 ( 209 ) 334-0723 CITY, STATE ZIP CA 95241 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. 1 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 FE L laws. APPLICANT'S SIGNATURE: DATE: 4412-o L2 PROPERTY / BUSINESS OWNER❑ OPERATOR MANAGER ❑ OTHER AUTHORIZED AGENT If APPLICANT is not the BILGING 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. AA %-- TYPE OF SERVICE REQUESTED: �p,1 S.iIJ6 i y elhCJ A)Yjr'-4e L".dirl %zev�t°ti✓ R N COMMENTS: VEZ SEp 3 SAN Jp v 2 22 hROpNM COUNn' ACCEPTED BY: C"% EMPLOYEE #: DATE: 3a ASSIGNED TO: F 1Q EMPLOYEE#: DATE: Date Service Completed (if already completed): SERVICE CODE: S,� 3 P / E: Fee Amount: 6,� y Amount Paid �'L! {. �— Payment Date 3,6 ZZ Payment Type J k Invoice # Check # 153Received By: EHD 48-02-025 SR FORM (Golden Rod) REVISED 11/17/2003