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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID# SERVICE RE ST# Ne ) �l SQ 5 5 X06 70 7 OWNER/OPERATOR �G1�S2 L S�Indor� j CHECKIfBIWNGADDRE'so FACILITY NAME /� � ` � .. ADDRESS 1. i`✓\ G C �1 ` �+ SITE 222 CV V 1 / 1 7b street Numher reWon street Name CI ZI Code HOME or MAILING ADDRESS (IfDifferent from Site Address) k R` e / SOaeCat—Number street Name 7 CITY - ra ST TEA ZIP PHONE#1 l L.I �! E"T APN# 60 � LAND Use APPucanoN# IS o �3� 5 PHONE#2 _ _l Exr. BOS DISTRICT LOCATON CODE CONTRACTOR/ SERVICE REQUESTOR REQUESTOR ©Wt 1.Qi1� CNECKKBILLING ADDRESS BUSINESS NAME -,!^�� PRONE#_,._. r ��^ OGZi HOME or MAILING AD DRE (1-7 �/�`� �� ol"I\ FA \O O W ^( ) CITY C STATE CA ZIP BILLING ACKNO EDGEMENT: 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 1 have prepared this ap 'cation and that the ork to be perfo ed will be done in accordance with all SAN JoAQurN <• COUNTY Ordinance Codes,Standar q j and FED R L lawww�. �� APPLICANT'S SIGNATURE: �J DATE: PROPERTY/BUSINESS OWNE - OPERATOR/ N:\GER ❑ OTHER AUTHORITED AGENT If APPLICANT iS not the BILLING PARTY Proof of authorization to sign is required Title AUTHORIZATION TO RELEASE INFORMATION: When applicable,J, 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 tlhe SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it Is available and at the Same Link' ,ts provided to me or my representative. TYPE OF SERVICE\\R'^EQUESTED: ,. ,, �/ 1 IVF r COMMENTS: e'11C.� purcl_eti� -,C=< ST f� ire hY�Q a� FO I T�spee +� 1v `s 6tiL� Ct \<Y e �94 1 tC e eoy X18 � g� Pefce.f�.k Why,+ yw\ �<4 C ��TNpF MFS Uy�Y A) CCA �TyNT ACCEPTED BY: EMPLOYEE#: r DATE: / AssIGNED TO: EMPLOYEE#: �f�'d� DATE: OO � Date Service Completed (if already completed): SERvICE CODE: ® /E: 1 Fee Amount: _ � �• �b Amount Paid � D Payment Date q` Payment Type do Ii KV- Invoice# Ch`ck# 1'fySSo Received By: EHD 48-02-025 ,1 ,,- y� J� EVISED 11/1 003 V '"`Q ^"tip �0`5 , C(71, SR FORM(Caolden Rod)