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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID# SERVICE REQUEST# I��l OWNER/OPERATOR ��n )- �`VIOL IO /C D M A} b i /� ^ CHECK 11 BIL4NG ADDRESS FACILITY NAME Vf 1. vlGtS 1,I LC. , ' `O 1. v li v l�, (�, SITEADDRESS 22� N A .. A G'I_c�Q�p1�T Ct S'Z(5 Street Number I Direction ll Street Name-`-"'C• T vCitZip Code HOME Or MAILING ADDRESS (If Different from Site Address) 2�---+ Street Number Street Name CITY G'k-lo C- STATE OA ZIP (�)t 5 2—,4,3 PHONE#i � EXr. APN# LAND USE APPLICATION# ( ) S L — 2122 PHONE#2 EXT. BOS DISTRICT LOCATION CODE ( ) CONTRACTOR / SERVICE REQUESTOR REQUESTOR CHECK If BILLING ADDRESS BUSINESS NAME PHONE# EXT. HOME Or MAILING ADDRESS FAX# CITY STATE ZIP BILLING ACKNOWLEDGEM T: 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.0Co certify that I have prepared this application and.dtat the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes,Standards,STATE an EDERA,laws. APPLICANT'S SIGNATURE: DATE: -2 2' PROPERTY/BUSINESS OWNER❑ OP TOR/MANAGER ❑ OTHERAUTHORIZED AGENT • IfAPPLICAN7'i8 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 an�j Ie same time it is provided to me or my representative. ` I ^ ,,, . ' TYPE OF SERVICE REQUESTED: V`ClVµ Ci�k (/t.Cp .�-fiQ/�/S`/�_ `��/ COMMENTS: O P �2 2Q S F/yAQU/N ACCEPTED BY: EMPLOYEE#: DATE: ASSIGNEDTO: - EMPLOYEE DATE: f Date Service Completed (if already completed): SERVICE CODE: l-L I PIE: O 3 Fee Amount: 91 rovouAmount Paid I Payment Date '--112-1 22— Payment ZPayment Type Invoice# 5 2 Received By: EHD 48-02-025 SR FORM(Golden Rod) REVISED 11/17/2003