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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST IAIR, S,Z- '1— I S: Or� Paid Type of Business or Property FACILITY ID # SERVICE REQUEST # HOME Or MAILI ADDRESS Gc> L FAx# ( ) SRm0gcoa49 OWNER / OPERATOR -- .M /cU CHECK if BILLING ADDRESS FACILITY NAME # 413-41 I SITE ADDRESS 62d S coq y, 7✓1 G"; -f Sr 1 Loo 1 r, _152 ® Street Number Direction EMPLOYEE M: Street Name city ZiD Code HOME or MAILING ADDRESS (If Different from Site Address)C Date Service Completed (if already completed): �O 934o Street Number S eet Name CITY I ILL IU ,• (� ( Y 0 _ PA N D C t/1 STATE ZIP C R S 6 S PHONE#1 Ex . APN # Invoice # LAND USE APPLICATION # I ) 2 0 RIH 91 S3 PHONE#2 En. ( ) BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR -FA RSE JiN/w1^ El "1 1 CHECK if BILLING ADDRESS /� BUSINESS NAME (]„c/�I �� D(�j� u PZaq) I HOME Or MAILI ADDRESS Gc> L FAx# ( ) CIN ( 3 G d STATE IP BILLING ACKNOWI i]�GEMENT: 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 an at the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, Standards, STAT and F D RAL laws. APPLICANT'S SIGNATURE: DATE: 0 I t3 2v22 PROPERTY/ BUSINESS OWNER IJ OPERATOR/ 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, 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 environmentaVsite assessment information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it Is available and at the same time It is provided to me or my representative. P4 V -deo— TYPE OF SERVICE REQUESTED:Ve'kirlp s Coosa I d i✓I p�+ r COMMENTS: JOq i Ht�AvtoOpAR M N ACCEPTED BY: S I I W EMPLOYEE M: DATE: D % ATE: ! - ! _� ASSIGNED TO: EMPLOYEE #: J Q Ll-- 1 DATE: _ 13✓.-� Date Service Completed (if already completed): SERVICE CODE: O /',.' PI E: Q '7 J Fee Amount: Amount Pal �� Payment Date � Payment Typej Invoice # Check # SSSF�2 Received By: EHD 48-02-025 REVISED 11/17/2003 SR FORM (Golden Rod)