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SAN JOAQUI, JUNTY ENVIRONMENTAL HEALTH 2ARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID# SERVICE REQUEST# &rv--ovl� �"AfF ! �� R tboG�-4,3I OWNER/OPERATOR J2© 1)AV*: M CHECK if BILLING ADDRESS E] FACILITY NAME AZ—9 SITE ADDRESS `��(l2 � I� yY)i►9�1 L�.� �v�c O4� , _o Street[[Nu>mber Direction Street Name Citv 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# ( ) PHONE#2 EXT. BOS DISTRICT LOCATION CODE ) CONTRACTOR/ SERVICE REQUESTOR REQUESTOR CHECK If BILLING ADDRESS f i BUSINESS NAME` CLYw�T _ ) PHONE# 1 Exr. HOME or MAILING ADDRESS j\•/ FAL# Z- CITY J ~,•-' STATE ZIP :52 le—v uC44 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 t e rk to be erformed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes,Standards,STATE an DE aws. A— PROPERTY/ APPLICANT'S SIGNATURE: DAT : moi'BUSINESS OWNER❑ OPERATOR/MANAGER 06 THEIR 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 DEPARTNfENT as soon as it is available and at the same time it is provided to me or my representative. TYPE OF SERVICE REQUESTED: ,r' O COMMENTS: WEI) 7 - /6- 13 JUN 2 4 2013 �1 c� SAN jo ENVAQUiN CpUNTV NEAT RCMENTAI f f DEPARTIIAL— ACCEPTED BY: r EMPLOYEE#: DATE: ASSIGNED TO: W tAk6, EMPLOYEE#: I�tCG DATE: � "C Date Service Completed (if already completed): SERVICE CODE: PIE: Fee Amount: v Amount Paid �?�� Payment Date 7 / Payment Type 00, Invoice# Check# Received By,*I--, EHD 48-02-025 SR FORM(Golden Rod) REVISED 11/17/2003 P/H 0 64 to zy�D--)