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T SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID# SERVICE REQUEST# OWNER/OPERATOR I l.uS Ck CN CHECK if BILLING ADDRESS 131 FACILITY NAME SITE ADDRESS lJ Street Number Direction Street Name Ci Zio Code HOME Or MAILING ADDRESS (If Different from Site Address) Street Number Street Name CITY STATE ZIP PHONE#1 EXT. APN fjt LAND USE APPLICATION PHONE#Z Ext. BC S DISTRICT LOCATION CODE CONTRACTOR/ SERVICE REQUESTOR REQUEST 1 ��-� �r I'-'�-� I� CHECK if BILLING ADDRESS BUSINESS NAME / �� r �\ PHONE# ExT. l—lr � 1 (-Lu " 9e1--323 HOME or MAILING ADDRESS { FAX# ► ��S m ms's C 11 (zp�t ) zr✓S-�J/ CITY ` —� ^ , l l Y L✓ STATE C- zip O'C-Z .7 V BILLING ACKNOWLEDGEMENT: 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 I have prepared this application and that the work to}be.performed ill be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes,Standards,STATE and FEDERAL71 ws. APPLICANT'S SIGNATURE: - pI DATE: PROPERTY/BUSINESS OWNER❑ OPERATOR/MANI d OTHER AU"CHORIZED 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 atsame time it is provided to me or my representative. PHYNACN 1 TYPE OF SERVICE REQUESTED: S C t L S C[ [`y` '7— S,n�6� " COMMENTS: �"Z' 00,3,�� Nov 2 3 200 SAN JOAQUIN COUNTY J AWaw ENVIRONMENTAL HEALTH DEPARTMENT ACCEPTED BY: DLC 0 C--( EMPLOYEE#: C, ASSIGNED TO: J �� EMPLOYEE#: 7 /- C �3(��fG DATE: Date Service Completed (if already completed): SERVICE CODE: r� y P 1 E: ZArn •O � Fee Amount� ( to (�O Amount Paid j I p Payment Date Payment Type o Invoice# ICheck# �(�( Received By: EHD 48-02-025 REVISED 11/17/2003 SR FORM(Golden Rod)