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SAN JOAQUIi )UNTY ENVIRONMENTAL HEALTH 10ARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID # BUSINESS NAME SERVICE REQUEST # P l' 34 i X13°� Cro0(;,27�� OWNER / OPERATOR CITY Z��k fl CHECK If BILLING ADDRESS L}I J— 1 '�J/ n r 1� `�V V DATE: Dote ServiDe Completed (if already completed): FACILITY NAME SERVICE CODE; a P E: �1 Lr SITE ADDRESS Amount Paid �� j NC b L N AVTf- C A 533 Street Number Direction Received By: Street Name cityzi Cotle HOME or ADDRESS (If Different from Site Address( rMAILING `• Ori Lj(—LJA 1 ` AFT Street Number Street Name CITY(� r �r _C. a J� ��j SATE ZIP 4 PHONE #1 En. APN # LAND USE APPLICATION # L�)D7)R33..c y,� PHONE #2 En. 8OS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR r ^ �a w/.J � /J 1r - _ �V E] CHECK if BILLING ADDRESSLJ BUSINESS NAME ,ulV SCOO HEtAAOVINRFRD�A-CMENj P l' 34 i p HOME or MAILING ADDRESS PC) ,/� D `' ,LJ l� EMPLOYEE #: 3 FAX # CITY Z��k STATE LP 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 dope in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, Standards, STATE and FEDERAL laws. APPLICANT'SSIGNATURE�\\ 7 DATE: 10�� PROPERTY/BUSINESS OWNER PERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ If APPLICANT is not the BILLING PARTY proof of authorization to sign is required Title AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, 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 �lF ne time It IS provided to me or my representative. DAA __. ,0 TYPE OF SERVICE REQUESTED: � „� Vk f Cr COMMENTS: ,ulV SCOO HEtAAOVINRFRD�A-CMENj ACCEPTED BY: EMPLOYEE #: 3 DATE: t/ ASSIGNED TO: EMPLOYEE#: 6913 DATE: Dote ServiDe Completed (if already completed): SERVICE CODE; a P E: �1 Lr Fee Amount: (,� ' Amount Paid `� Zq D -D Payment Date U I / Payment Type ✓ invoice # Check # Z3 Received By: EHD REVISED 00 X0701 NO REVISED 11/17/2003 SR FORM (Golden Rod)