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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property11FACILITY ID # SERVICE REQUEST # (CI O 1 t•L S Qj T tAn ) g fAl�l2��2 �S�IS OWNER / OPERATOR PHONE# `1�D (+lS �� (• �� t CHECK If BILLING ADDRESS O FACILITY NAME "^ erca�n 1'S p(Lza, /c?i—(92911 sITEADDREss ?q Street Number FAX# Dim. Non g HOME Or MAILING ADDRESS (N Different from Site Address) C II Cotle — I ) C4tt CJ r CITY STATE CA Street Number StreetN me Ldd CODE: O/ STATE zip PHONE #i En. APN# `1 S y Z LAND USE APPLICATION# 611.1 Co2111 - 3 Z 77�� Payment Type PRONER ( ) Ezr. BOS DISTRICT Check # S LOCATNJN CODE CONTRACTOR / CF.RVTC'F. RFniTi C'rniD REQUESTOR (CI O 1 t•L S Qj T tAn ) CHECK if BILLING ADDRESS BUSINESS NAME t v rr mast's P12z�t PHONE# Eur ACCEPTED BY: oT I /c?i—(92911 HOME or MAILING ADDRESS FAX# ASSIGNED TO: 5-(o u- Caektk1 br I ) cj D CITY Lc? r k I STATE CA zip ri r LyZ BILLllVG ACKgOM LEUGEMFNT: 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, STA?'E�d FED/gRAL laws. APPLICANTS SIGNATURE: //[/ DATE: S 'y PROPERTY/ BUSINESS OWNERIM OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ If APPLICANT is not the BILLING PARTY Proof of authorization to sign is required Title AVMORIZATION TO RELEASE INFORMATION: When appkicable, 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 t0 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. TYPE OF SERVICE REQUESTED: COMMENTS: ACCEPTED BY: P EMPLOYEE #: L ^1 DATE: 3 �f O 2-3 LZ D� ASSIGNED TO: ( EMPLOYEE #: cj D DAA; 2 �✓ JpiE; Date Service Completed (If already complet SERVICE CODE: O/ /6 n 2 Fee Amount: Amount Paid` S' b Payment Date - 3 Z 77�� Payment Type L L Invoice # Check # S p U Received By: EHD 48-02-025 REVISED 11/17/2003 ?F,05151 bI SR FORM Iden Rod)