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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property I CHECK If BILLING ADDRESS FACILITY ID # i n �i ane SERVICE REQUEST # RPS vran� HOME or MAILING ADDRESS t EMPLOYEE#: DATE: FAx# CITY n OWNER I OPERATOR " - - R STATE /t ZIP �'33 7 /'^ r h 2 cA2 CHECK If BILLING ADDRESS SERVICE CODE: P / E: UU2 ✓f\ � Amount Paid 5/,, -- FACILITY NAME r a t l n Received By: S n 0/ SITE ADDRESS ', 1005 QQ✓ o I ,, �QSC2�Gro Xl. S4t 10 1 -Ffa Ci (J I53®y Street Number Direction Street Name It ZI Coae HOME or MAILING ADDRESS (If Different from Site Address) J I [ 1 19571 (1� Ole a� V er /� ve Stree/t Number Street N^ame�i CITY r ^n I STATE CA zip '19337 PHONE #t lz� . APN # LAND USE APPLICATION # (20q) qZ0- 52ZI PHONE #2 I ) Ex . BOIS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTORSaa�ln 'der I CHECK If BILLING ADDRESS BUSINESS NAMEPH ria S i n �i ane ENVIRONMENT HEALTH DEPARTM EXT. ( ) q2O-5221 HOME or MAILING ADDRESS t EMPLOYEE#: DATE: FAx# CITY n (J STATE /t ZIP �'33 7 BILLING ACKNOWLEDGEMENT: 1, 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, ZZ F RAL laws. APPLICANT'S SIGNATURE: , DATE: 2 PROPERTY/ BUSINESS OWNER [3 I OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ ffAPPLICANT 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 propertPUMENT above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental'REGEIVED 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. FER 0 3 TYPE OF SERVICE REQUESTED: '�—V c\- COMMENTS: \^ ENVIRONMENT HEALTH DEPARTM ACCEPTED BY: \ L- EMPLOYEE#: DATE: 2 R 2 ASSIGNED TO: I (J EMPLOYEE #: DATE: 2 cA2 Date Service Completed (if already Completed): SERVICE CODE: P / E: UU2 Fee Amount: � � Amount Paid 5/,, -- I Payment Date 9 Zi7 2 3 Payment TypeV S Invoice # Checlt # / ;- 2_ Received By: EHD 48-02-025 REVISED 11/17/2003 Q(L06L13t�lq SR FORM (Golden Rod) NTY L ENT 5