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SAN JOAQUIN )LINTY ENVIRONMENTAL HEALTH T .RTMENT SERVICE REQUEST Type of Business or Property FACILITY ID # CHECK If BILLING ADDRESS SERVICE REQUEST # OWNER /OPERATOR Ca4WLVL6 , tU�'n C6� CHECK if BILLING ADDRESSO FACILITY NAME�Vv��+J HOME or MAILING ADDRESS ( 10 Q0ldrlV1 1kL) DATE: P SITE ADDRESS(Fib 1 Street Number 1 , ( Directlon 14AS I Street Name STATE ( A Ci t� S37T„ Zip Code HOME or MAILING ADDRESS (If Different from Site Address) Street Number P 1 E: 2?� A Street Name Amount Paid ��jT D CITY STATE ZIP Payment Type ✓ PHONE #1 ExT• ( ) APN # LAND USE APPLICATION # Received By: PHONE #2 EXT. BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR ' ( a W a�-kmaw I CHECK If BILLING ADDRESS BUSINESS NAMEPHONE# S er�r� c.e staAtov� S S tos p, JI ACCEPTED BY: Alk- EXT. HOME or MAILING ADDRESS ( 10 Q0ldrlV1 1kL) DATE: P FAx # (-tot) ':a(3 - CITY S &w 'iosc STATE ( A Zip q sl t 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: 'A4Li. U • DATE: -i c`SMF �DIN� ltfitlte dTT��f� PROPERTY/ BUSINESS O WNER ❑ OPERATT OR /MANAGER ❑ 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 environmentaVsite 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: �\ �-'c4� c - I COMMENTS: SS S I( jt-vL -[U-- t �i S` l (l l l aou,.t\J ev Ct* p, JI ACCEPTED BY: Alk- EMPLOYEE #: j� b t✓ DATE: P ASSIGNED TO: U EMPLOYEE #: DATE: Date Service Completed (if alrea'd`y+ pleted): SERVICE CODE:l —1 P 1 E: 2?� A Fee Amount: ja2q.Cc Amount Paid ��jT D Payment Date S Z 6 Payment Type ✓ Invoice # Check # lZd Received By: EHD 48-02-025 SR FORM (Golden Rod) REVISED 11/17/2003 v� E vEQ 2 2 ti��6 GCVN� o�aU�MEN�tP�N N o PPR�M