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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property BUSINESS NAME ,01094 „"'j _ f /r,CD rr/le'4 Y1J Vt/l/L/ FACILITY ID # HOME or MAILING ADDRESS -7 SERVICE REQUEST # CITY STATE 01 ZIP �JO SQ oDBs�Z�j OWNER / OPERATOR / 11 "x G�lr ` L..1rG V\J CHECK 11 BILLING ADDRESS FACILITY NAMEnn yr �Kgrk SITE ADDRESSIJI �li ,7 ACCEPTED BY: VA l L 7'S �- I i/`� EMPLOYEE #: DATE: ASSIGNEDTO: eF. Street Number Diredlon Street Name Date Service Completed (if already completed): city Zip Code HOME Or MAILING ADDRESS (If Different from Site Address) L4-7 Lo w ��v`A �� T\� Fee Amount: Street Number Amount Paid Xft Street Name CITY _ a 2�-(V2Z. STATE 04 ZIP �1� PHONE#11 Ev. c 56)q APN# LAND USE APPLICATION# PHONE#2 En ( ) 6;>u- 229- 21S; BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR A- - n G` vfVtvh f�/j CHECK ifBILLING ADDRESS BUSINESS NAME ,01094 „"'j _ f /r,CD rr/le'4 Y1J Vt/l/L/ PHONE# Ems' ( ) HOME or MAILING ADDRESS -7 FAX# CITY STATE 01 ZIP BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or project specific ENvtRONMENTAL 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 wild be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, Standards, STATE and FEDERAL laws. APPLICANT'S SIGNATURE: � a,, / C; 4 9,112, 2 PROPERTY / BUSINESS OWNER❑ OPERATOR / MANAGER ❑ OTHER AUTHORIZED AGENT ❑ If APPLICANT is Not the BILLING PARTS' 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 environmentaVsite 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. OAv_ TYPE OF SERVICE REQUESTED: C. U V Cskk' R NT COMMENTS: ^ , � S�F� 2 �JO 1lj ftfM Afry yr �Kgrk ACCEPTED BY: VA l EMPLOYEE #: DATE: ASSIGNEDTO: eF. EMPLOYEE#: DATE: Date Service Completed (if already completed): SERVICE CODE: P I E: rl Fee Amount: Amount Paid Xft a Payment Date 2�-(V2Z. Payment Type 0 ouzInvoice # c 56)q Received By: EHD 48-02-025 REVISED 11/17/2003 v SR FORM (Golden Rod) M COQ -0 " 71 V5 S.