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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property CHECK if BILLING ADDRESS FACILITY ID # SERVICE REUEST # emu •Ir%JI &t N I FAX## MrTl NMr4.t.LVV SQ O��S�St I ) OWNER/ OPERATOR STATE C ZIP �L � MAY IRo vfe ^ O Op I j��' V� / ! C �- CHECK If BILLING ADDRESS J FACILITY NAME Moi ek OU r Pka v ir'S d -P' POMCL- Medi Ca 8 a SITEADDRESS Stree W Number Oire( U Ma�� k.AYaR.! SVr 2 104 �N HOME or MAILING ADDRE� i S (If Different from Site Address) Stree! Ci Zi Cade CITY Street Number Street Name 02 ASSIGNEDTO: t I EMPLOYEE#: / DATE: / J STATE ZIP ted (if already completed): PHONE#I Ev. Fee Amount: APN # I' eZ AmounlP ' LANO USE APPLICATION # Payment Date 5110122 22 PHONE#2 El. ( � I Z5G.� Invoice # Check # lY-3 BOS DISTRICT LOCATION CODE CONTRACTOR /SERVICE REQUESTOR RE UESTQR BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, CHECK if BILLING ADDRESS BUSINESS N ME uro � l' R �• pppNc# ) — Ell HOME or MAILING ADDRE S FAX## MrTl NMr4.t.LVV I ) CITY(& 401 i STATE C ZIP �L operator or authorized agent of same, acknowledge that all site and/or project specific ENVRIONMENTAL 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 preparedWTOR te work to be performed will be done in accordance with all SAN JOAQUTN COUNTY Ordinance Codes, Standlaws. APPLICANT'S SIGNATURE: DATE: S�Z 170 �.7 _ PROPERTY T BUsuiESs OWNER❑❑ OTHER AUTHORIZED AGENT❑ IfAPPLTCANT is not the BILLING PARTY yiroaf of authorization to sign is required Title AUTHORIZATION1TO 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 myliepresentative. _ t:oNF• of tN3378840 EHD 48-02-025 � I SR FORM (Golden Rod) REVISED 11117/2003 TYPE Of SERVICE REQUESTED: O � /•i tZ� R �• COMMENTS; VC � MAY 10 / sgNTyD4 aR"?pN2y Try ACCEPTED BY: .4 V I Cv 1-4 EMPLOYEE M n DATE; _I 02 ASSIGNEDTO: t I EMPLOYEE#: / DATE: / J Date Service Compl ted (if already completed): SERVICE CODE: P 1 E: / Fee Amount: a I' eZ AmounlP ' `�'� O OD Payment Date 5110122 22 Payment Type Z5G.� Invoice # Check # lY-3 ecetved By: �