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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property CHECK if BILLING ADDRESS "V BUSINESS NAME FACILITY ID # SERVICE REQUEST # HOME or MAILING ADDRESS DCI ` S r. e FAX # in ) CITY Tt-O. STATE CF'Y ZIP li316 OWNER/OPERATOR �t 111 CHECK If BILLING ADDRESS FACILITY NAME ACCEPTED BY: b�•- EMPLOYEE #: DATE: ASSIGNED TO: p� �Q. Q SITE ADDRESS U EMPLOYEE #: C601 yI �9tr'eet J S �CI n Oei:76 treat Number Direction / j� �7j Name Payment Date Zio Code HOME Or MAILING ADDRESS (If Different from Site Address) Invoice # T- Check # /3 8S Received By: Street Number / ilV✓ �C. Street Name CITY Trac STATE n zip j'i S PHONE#1 Ezr• APN# LAND USE APPLICATION# (SID ) 83-1 -foal PHONE#2 En. BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REOUESTOR REQUESTOR CHECK if BILLING ADDRESS "V BUSINESS NAME bio �t� pec (LG PHONE# En. (SLO 31 — LINI HOME or MAILING ADDRESS DCI ` S r. e FAX # in ) CITY Tt-O. STATE CF'Y ZIP li316 BILLING ACIOrOWLEDGEMENT: 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: �,4y i Wt— DATE: 3/3/ZZ PROPERTY / BUSINESS OWNERt7L OPERATOR /MANAGER ❑ OTHER AUTHORIZED AGENT ❑ IfAPPLlcANT i,T not theStLUNGPAR proofof authorization to sign is required Titre 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 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. ibw._ TYPE OF SERVICE REQUESTED:—7y-bp( �— ��J 1 r�,f I? '#'-'•? COMMENTS:D Mq� 03 ?f7 %J ?? 47hDZu;� kT ACCEPTED BY: b�•- EMPLOYEE #: DATE: ASSIGNED TO: p� �Q. Q EMPLOYEE #: DATE: "7 ---Jf'7 Date Service Completed (if already completed): SERVICE CODE: P.1 E: 3 Fee Amount: / j� �7j Amount Pai6,01 Payment Date 3 2.2— 2Payment PaymentType �� Invoice # T- Check # /3 8S Received By: EHD 48-02-025 REVISED 11/17/2003 SR FORM (Golden Rad)