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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT S-'5Z-D SERVICE REQUEST Type of Business or Property FACILITY ID # L4- SERVICE REQUEST # 5 Kt) 0 5 724:7 OWNER! OPERATOR CHECK if BILLING ADDRESS FACILITY NAME Q, .,:.4 r-, \ v\\ f t\z,,,i--- S PA-- --- '14 4C..r--- SITE ADDRESS lo (-k 6 :1,— Street Number N Direction W e:-->\- 1_ 0,v\,.._ Street Name 5\co(-\`‘ \t:>N• City cl 52. \C_i Zip Code HOME Or MAILING ADDRESS (If Different from Site Address) Street Number Street Name CITY STATE ZIP PHONE #1 EXT. (1-tA i--\11,- 55\kir, APN # 0 q LE -o_<o- 2_9 LAND USE APPLICATION # PHONE #2 EXT. ( ) BOS DISTRICT 2_ LOCATION CODE 1 CONTRACTOR / SERVICE REQUESTOR REQUESTOR CHECK if BILLING ADDRESS BUSINESS NAME %-.c-it-Te_. -kki g V (..,,_,A --.?\ c.,,,,-Ar>.<-•:y,,, I YU_ - PHONE # (Z-0:t) ,541..:43 II EXT. HOME or MAILING ADDRESS 6 0 N. A--rytA c,...ve..... ..., .1 9NA FAX # (14 3) 5 iS. 29,1-tx CITY c., STATE ZIP 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--f-A.- DATE: PROPERTY / BUSINESS OWNER El OPERATOR / ANAGER El OTHER AUTHORIZED AGENT If APPLICANT 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 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 rovided to me or my representative. _ TYPE OF SERVICE REQUESTED: ie.......c.._ 14 E .4._c _77-{ R_E- i t-t 0 4 cc__ /4-,.) 6.1- 4 E-Ce---- A&Nis• 4C. 4 MAY - 7 2:n SAN JOAQuIN u HEALTH DEPAii „ ACCEPTED BY: d-,) 6_1 , jet "..04_ EMPLOYEE #: DATE:„57....7foci DATE: ASSIGNED TO: c c), o EMPLOYEE IP 0 LC 6,7 Date Service Completed (if already completed): SERVICE CODE: 5. 2, 2__ NEI ( 4 , 0 2 _ Fee Amount: it_2_,0 .0) Amount Paid Z, 0 --- Payment Date S 7 / 0 9 Payment Type kv----- Invoice # Check # 0 k• F-0 Received By: N-q— SR FORM (Golden Rod) END 48-02-025 REVISED 11/17/2003