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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID # PHONE# Ems' SERVICE # FAx# E 1REIQUEST LA t-41(Dq OWNER / OPERATOR_ it /( y, 1 �� (� � / Alt-e) 31 CHECK If BILLING ADDRESS FACILITY NAME 5 / / -. - —`f� l- (, P r /./ 0 t lJ( �i (i - SITE ADDRESS I I Street Number Direction Street Name City Zip Code HOME or MAILING ADDRESS (If Different from Site Address) �� P4- 5 �/Z—C' Street Number Street Neme ({� STATE J ZIP ` .J (�APPLICATION APN # LAND USE # `(NW v (—'7 �T� / 0 1 PHONE #2 Ev. BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR /L_T rj 'AIL__ Ai / J CHECK If BILLING ADDRESS 13 J/ �r!—N BUSINESS NAME ' PHONE# Ems' HOME or MAIL GADDRESS 5% Lif,C r +5_7 FAx# CITY / I / !> STATE ZIP 7 72 O 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 DERAL laws. APPLICANT'S SIGNATURE: DATE: PROPERTY/ BUSINESS OWNER OPERATOR/ MANAGER ❑ OTIIER AUTHORIZED AGENT ❑ If APPLICANT is not the BILLING PARTS' proof of authorization to sign is required rifle 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. PAA,&._ TYPE OF SERVICE REQUESTED: COMMENTS: .1UN28 sJOAQUt6 217EN(7R N CC HE9CrH p pMl NTACNT I Nn s �rMFyr ACCEPTED BY: EMPLOYEE #: qp7o DATE: QI ZZ ASSIGNED TO: EMPLOYEE#: 405 DATE: CP Wu - Date Service Completed (if already completed): SERVICE CODE: 27J PIE: ILL0' Fee Amount: Amount 134> — Payment Date 2 22 Payment Type ti Invoice # Check #-R- / Received By/ EHD 48-02-025 REVISED 11/17/2003 SR FORM (Golden Rod)