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SAN JOAQUIN COUNTI' EN�'IRONN1a=NTAL HEALTH DEPARTMENT SERt'►CE REQUEST Type of Business or Property CHECK if BILLING ADDRESS FACILITY ID # SERVICE REQUEST # ad 3 S idh on , �� �w090 tiw V Z -1�0 /400-"0S`l - OWNER/ OPERATOR FAxK##[�, !% (lf ) 2. Iga CHECK If BILLING ADDRESS 1 cp - ( TE ZIP ( AGFACILITY NAME 1 ASSIGNED TO: QVeA L) SITE ADDRESS % EMPLOYEE #: (!A06t Rvis . Lodi 952�fQ. Street Number Direction 'L=Z' Cq) Street Name Cit Zi Code I�) . Payment Type HOME Or MAILING ADDRESS (If Different from Site Address) Check # O p d Received By: Street Number Street Name CITY STATE ZIP PHONE #1 APN # LAND USE APPLICATION # ( ) - 2 nCtEXT. PHONE fit xT. BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR i`�l 11n CHECK if BILLING ADDRESS BUSINESS NAME r P N EXT. A,Nnoo Ntflt�d0 1. tiw V Z -1�0 HOME Or MAILING ADDRESS (33A`�Atld FAxK##[�, !% (lf ) 2. Iga .� CITY cp - ( TE 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: *M (.JlXu DATE: (rT_�1 PROPERTY/ BUSINESS OWNER❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT ( party— 1n]ta -e If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required —'i 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 Drovided to me or my representative. EHD 48-02-025 SR FORM (Golden Rod) REVISED 11117/2003 TYPE OF SERVICE REQUESTED:BUM,, COMMENTS: A,Nnoo Ntflt�d0 tiw V Z -1�0 (33A`�Atld Iga ACCEPTED BY: `�h . n EMPLOYEE #: DATE: j (� ( ASSIGNED TO: QVeA L) EMPLOYEE #: DATE: Date Service Completed (if already Completed): SERVICE CODE; PIE: VOY Fee Amount: Amount Paid 'L=Z' Cq) Payment Date I�) . Payment Type Invoice # Check # O p d Received By: EHD 48-02-025 SR FORM (Golden Rod) REVISED 11117/2003