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SAN JOAQUIN COUNTY ENVIRQNMEN`fAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID # BUSINESS NAM�Er t �tl�{ Ay A4 I &6V--� SERVICE REQUEST # J'W OWNER/ OPERATOR A^ /CO� jJV 0 MrN C J ,•6 CHECK If BILLING ADDRESS FACILITY NAME t d it_� vk /L� V r/ v6t4 �qlf( � I `V�7L� �l DATE: SITE ADDRESS '� Street Number Direction l (—V �� Street Name DATE: L•/`+� / 01 !^� cit .,,y(J _ r ZI Code HOME or MAILING ADDRESS (if Different from Site Address) t� Street Number Fee Amount: M tS7-y M��)dw -r Street Name G'^—r r�.� , CITY S--,r6 ,/ Payment Date STATE On ZIP " LJ PHONE #1 `]`+Y ,„/" E"• (wq )� APN # Check # 0nJ 2_q LAND USE APPLICATION # PHONE #2 Ex . ( ) BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR I n / / "� ' — oa M i ^) r_ r \ V IK �..fyt� t�/VCC"V CHECK If BILLING ADDRESS BUSINESS NAM�Er t �tl�{ Ay A4 I &6V--� PN9) 6 y 9 E. . HOME or I MAILING ADDRESS S T N t e- C1 .J , A' w s T (AX# ) CITY /irT�� C /C STATE ZIP 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 perlorme Ill be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, Standards, STATE E L 1ws kh� / 15 APPLICANT'S SIGNATURE: DATE: PROPERTY / BUSINESS OWNER OPERATOR/ MANAGER O OTHER AUTHORIZED AGENT ❑ If APPLICANT is not the BILLING PART}" 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/ ' e assessment information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at th a it is provided to me or my representative. R TYPE OF SERVICE REQUESTED: Allf, ZAO COMMENTS6 �o UtN Co�� ACCEPTED BY: EMPLOYEE#: DATE: ASSIGNED TO:EMPLOYEE #: DATE: L•/`+� Date Service Completed (if already completed): SERVICE CODE: D P / E: % Fee Amount: Amount Pai �G Payment Date Payment Type Invoice # Check # 0nJ 2_q Received By: EHD 48-02-025 SR FORM (Golden Rod) REVISED 11/17/2003 f� o c� '©