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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property wfl S V� I 0 r I ' `ec FACILITY ID # SERVICE REQUEST II Com Cc. SROoTopo OWNER/ OPERATOR NLUIl�1`� CiECK if BILLING ADDRESS eO(' U Zrrnn C'C FAMffNAEE P 1/�.(, W a� SDE ADDRESS C FAX# DATE 101/0 19,2-- Z 2 0 rr 9 S 3Z a L--, Lq '�tr Numthc IN.S. \ Name CD" Code rHOtff NAI ADDRESS (If Different from Site Address) Checkif I,5-1 T4I`tom ZC4'1 Street Number Street Name CrrYU STATE zipUAhn PND1Ei E'' APN # LAND USE APPLICATION # IZOgI 232 a Nus PMM12 ET- BOS DISTRICT LOCATION CODE I 1 CONTRACTOR / SERVICE REQUESTOR 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, STATE and FEDERAL laws. p� APPLICANT'S SIGNATURE: � DATE: IV 'IO -ZZ PROPERTY/ BUSINESSOWNERCI OPERATOR/MANN R OTHER AUTHORIZED AGENT❑ I,fAPPLICANT is not the BILLING PARTY. pra0f 0f authoriZat%dn 10 Sign i5 required ritte 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 JOAQUN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative, PAVAsa - TYPE OF SERVICE REDOESTED: wfl S V� I 0 r I ' `ec CNECK if BILLING AooREss 121 e 6 E IO/RONINCOUN HST H OF/MRfvrAL BUSNM HAM TI✓FNT PNONE # E C'C (Log 2 �1 HOES orYAuwG ADDRESS FAX# DATE 101/0 19,2-- Z 2 0 rr I PIE: `m STATE CA "P`9532-0 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, STATE and FEDERAL laws. p� APPLICANT'S SIGNATURE: � DATE: IV 'IO -ZZ PROPERTY/ BUSINESSOWNERCI OPERATOR/MANN R OTHER AUTHORIZED AGENT❑ I,fAPPLICANT is not the BILLING PARTY. pra0f 0f authoriZat%dn 10 Sign i5 required ritte 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 JOAQUN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative, PAVAsa - TYPE OF SERVICE REDOESTED: wfl S V� I 0 r I ' `ec COMIENrs: OCT 10 zozz 6 E IO/RONINCOUN HST H OF/MRfvrAL TI✓FNT r 64 L(1 ACCEPTED BY: EMPLOYEEP �1G ✓ DATE: fO IO y2' ASSIG ED TO: cv�/ EmPLOYEE$'. y,I -7 ZKY DATE 101/0 19,2-- Z Date Date Service Completed (if already completed): SERVICE CODE: lX I I PIE: Fee Amount Amount Paid Payment Dale 5 / 2 Payment Type Invoice Checkif I,5-1 T4I`tom By. EHD 48-02-025 REVISED 11[172003 SR FORM (Golden Rod)