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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property CHECK If BILLING ADDRESS FACILITY ID # SERVICE REQUEST. # r-, I NC K PHONE 2— 2 7. C HOME or MAILING ADDRESS r� 10�j3l TY KE llK (AX# ) OWNER/ OPERATOR STATE (tl ZIP Q S 2-Q CHECK if BILLING ADDRESS FACILITY NAME T h l- SITE ADDRESS 163 Z 1 Y K E DR SjoGK To N gS2o Street Number Dlreotlon Street Name city ZIP Code HOME or MAILING ADDRESS (If Different from Site Address) Street Number Street Name CITY STATE ZIP PHONE#1 ExT APN # LAND USE APPLICATION # (2M) 2262,- 94 Zz PHONE#2 En. ( ) BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR r� S 1 11 CHECK If BILLING ADDRESS 1e POO rV it BUSINESS NAME 1 1 A N EX r� Y^ r-, I NC K PHONE 2— 2 7. C HOME or MAILING ADDRESS r� 10�j3l TY KE llK (AX# ) cry S 1 dC TON STATE (tl ZIP Q S 2-Q 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 FEDERQt laws. APPLICANT'S SIGNATURE: ?AI.� DATE: © 3/ 21 Z PROPERTY/ BUSINESS OWNER❑' 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 environmentaUsite 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. pw%,_ TYPE OF SERVICE REQUESTED: COMMENTS: MaK z 12 'IV COU ACCEPTED BY: EMPLOYEE #: DATE: ASSIGNED TO:I ' EMPLOYEE #: ,21 j DATE: 13 Hyl y2, Date Service Completed (if already completed): SERVICE CODE: �. P 1 E:'(,(U� Fee Amount: Ok Amount Paid / Payment Date Payment Type n 17 /. I Invoice # C, 4. 1 Lq r —[q2C.f C> I Received By: EHD 48-02-025 REVISED 11/17/2003 SR FORM (Golden Rod)