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SAN JOAQU4r—OUNTY ENVIRONMENTAL HEALTWPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID# SERVICE REQUEST# t'j�- ( o �� l s - 067W 19 OWNER/OPERATOR �' -` � CHECK If BILLING ADDRESS FACILITY NAME {/�-Y c vc llliiivvv M1M1M1V1 Vim+ YO•. SITE ADDRESS � r vov 15 5 �� Street Number Dir tion Street Name Cit Zip Code HOME or MAILING ADDRESS (If Different from Site Address) Street Number Street Name CITY STATE ZIP PHONE#1 EXT• APN# LAND USE APPLICATION# (109 ) 'to-; - 063B vyoa� PHONE#2 EXT. SOS DISTRICT LOCATION CODE 9 Cl CONTRACTOR/ SERVICE REQUESTOR REQUESTOR i 11 �w Te-V rl- CHECK if BILLING ADDRESS BUSINESS NAME �CVe_V` C-Cla sk0n PHONE# q EXT• C Z09 L.� 1 —6foL�o HOME or MAILING ADDRESS FAX# %2-&. (20,3) Lt-+ Ct — Lf p I{4 CITY ES Cc(Q l.STATE C k ZIP J � 'Pt. 415 3�.6 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 a d laws. APPLICANT'S SIGNATURE: DATE: PROPERTY/BUSINESS OWNER[3OPERATOR/MANAGER 1:3OTHER AUTHORIZED AGENT bd kyure l[ki_,.. If APPLICANT is not the BILLING PARTY proof of authorization to sign is required Title E>PeAr0-k- %--S 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. I TYPE OF SERVICE REQUESTED: r COMMENTS: /'O top �`Ty�Epq�N MFNT ACCEPTED BY: EMPLOYEE#: Sq-7 DATE: ASSIGNED TO: '�w 1-�-�-`•-- EMPLOYEE#: 9 i DATE: I Date Service Completed (if already completed): SERVICE CODE: P 1 E: /� Fee Amount: / Amount Paid �S�LPa ment Date � ` "/ Y S 7 7z;��L:7d Payment Type �1 Invoice# a 6 _! Check# oZ Rec ved By EHD 025 /) / SR FORM(Golden Rod) REVISEDSED 11/17/2003