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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property 3AKeigNi ICE ckEibt4 6Hoe FACILITY ID # - 1'78 8 L./ iLI-Peug-t-/ SERVICE REQUEST # , \ n OWNER! OPERATOR 6Cfcjio frIctr4tnez. CHECK if BILLING ADDRESS FACILITY NAME A PI I 1ENTA C I Oki 8P ISC y AIIID _ICC: ceEaik-i 51-/OP SITE ADDRESS Z CI S-- Street Number Direction piozo flue nue 46 Street Name &7 I e c; alon City 953 Zip Code HOME Or MAILING ADDRESS (If Different from Site Address) laglaW Street Number Street Name CITY STATE ZIP PHONE #1 EXT. ( Wq ) 5-68 —Z6-93 APN # LAND USE APPLICATION # PHONE #2 Err. ( ) BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR er go ,..)401, -I. i ne2 CHECK if BILLING ADDRESS BUSINESS NAME M I Te A71' /look) 6)Ats&l2-v /I Az ;ice ceefim s NoP PHONE # ( ) EXT . HOME or MAILING ADDRESS 6093 gq-beccq Larvz ( FAX # ) CITY A r- tver 60,-)K STATE c/c) ZIP cis 36. ....-71 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 FEDERAL laws. APPLICANT'S SIGNATURE: 7/1 (?/r /11#11714/Ax-f- 5- DATE: /Cle/F- I PROPERTY / BUSINESS OWNERPI. OPERATOR / MANAGER 0 OTHER AUTHORIZED AGENT 0 If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required 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. TYPE OF SERVICE REQUESTED: ff vs rme,,, ; . RE 'N7 COMMENTS: l LIEC 0 82021 'AN JoiaQui , ii4^Aviolvi,g,otiNry rti Dep,„prAL Fwah,f6Air ACCEPTED BY: Liji [Aro ,S.- EMPLOYEE #: (;2---6 ) DATE: ASSIGNED TO: C.447 Ifyieuti L .....f . EMPLOYEE #: g7 n DATE: 12_ Date Service Completed (if already completed): SERVICE CODE: SO:3 P / E: / 6/ Fee Amount:4 kfrg-t, '00 Amount Paid 2-f57 e /----- Payment Date I ---list2A Payment Type a, out& Invoice # Checaga 4 1 1 3,6 4-4_ L+,9 03 Received By: ai0-7(1. Title EHD 48-02-025 REVISED 11/17/2003 SR FORM (Golden Rod)