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SAN JOAQUIN COUNTY ENVIRONMENTAL 14F AT TH DEPARTMENT SERVICE REQUEST eetotf Business or Property Type '"(Q7�1CU� S VY Ifo CHECK If BILLING ADDRESS A FACILITY ID # �F1OV��1�2 (1 �C. SERVICE REQUE/S�T # OWNER I OPERATOR Ct �Y- J 1 `�r�1nC CHECK If BILLING ADDRESS❑ FACILITY NAME STATE ZIP ASSIGNEDTO: L/ �m•t �- SITE ADDRESS reet Number Direction e creel Name Q✓\ 5 2 Lang LD d t CI Zip Code HOME or MAILING ADDRESS (If Different from Site Address) Street Number Street Name CITYSTATE Sam M ' .( 15`lo C YL�j ZIP olr PHONE #t Exr. Mot) VIZI — `t Payment Type APN # LAND USE APPLICATION # PHONE #2 Ext. ( ) Received By: BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR (1 n Ifo CHECK If BILLING ADDRESS BUSINESS NAME gYrl (1 �C. P PHONE p E t/Ott _L — yO ZLi HOME Or MAILING ADDRESS IsIO Ct �Y- J 1 `�r�1nC FAX# ( I CITY 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 performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, Standards, STATE and FEDERAL laws. `] APPLICANT'S SIGNATURE: DATE: I' PROPERTY/ BUSINESS OWNEW6 OPER%1 .AGER❑ OTHER AUTHORIZED AGENT If APPLICANTis not the BIL G 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 die SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as Soon as it is available and atI��gip Ate_ e time It is provided to me or my representative. PAX � /M'eNlp TYPE OF SERVICE REQUESTED: C e�V COMMENTS: IVUY 4JOA 7022 ek?pEpA 1 7Y NT ACCEPTED BY: edr Zit Q EMPLOYEE#: DATE: IIS -20Q, ASSIGNEDTO: L/ �m•t �- EMPLOYEE#: DATE: _ Date Service Completed (if already completed): SERVICE CODE: I PIE: 0 Fee Amount: 1 S Amount Pat /5C� did Payment Date 1y Payment Type Invoice # Check # 15�/-{-5 (o Received By: EHD 48-02-025 REVISED 11/17/2003 ?'t Ie2334 SR FORM (Golden Rod)