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`. SAN JOAQUIis,OUNTY ENVIRONMENTAL HEAL'IdFPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID# SERVICE REQUEST# ,;SERVICE OWNER/OPERATOR Dr Cr e e� a\\ CHECK It BILLING ADDRESS FAcIurY NAME - - SITE ADDRESS 2 X151 ,I„ ' ce rJ Qd C ayh 195220 - Street Number Direction Street Name C' Zip Code HOME or MAILING ADDRESS (Ifniiferent from Site Address) S r--t Street Number Street Name CITY S ^ STATE LP \ PHONE#1 TET' APN# LAND USE APPLICATION# PHONE#2 Er. SOS DISTRICT LOCATgN CODE t ) CONTRACTOR/ SERVICE REQUESTOR REQUESTOR C CHECK if BILLING ADORES BUSINESS NAME `t PHONE# Ev. C Mir V\e4- r . — CI 611� ^ , Q Ai —657-75 HOME or MAILING ADDRESSFAX# 22\ W esu S� w -'Z-- (2M( ) - 261) CITY STATE C A ZIP '72-46 BILLING ACKNONVLEDGEMENT: 1, the undersigned property or business owner, operr�ator or authorized agent of same, acknowledge that all'site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this projector 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'SSIGNATURE: {� � DATE: PROPERTYIBUSINESSOWNER❑ OPERATOR/MANAGER OTHERAUTHORIzED ACENTP a4f Dio -nin IfAPPLJCANT 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 at the sable time it is provided to me or my representative. FWTIVIENT TYPE OF SERVICE REQUESTED: cS Olt_ ,S l.ttTy�B IC_( S'jZ.[to RECEIVED COMMENTS: JUN 2 12004. SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT ACCEPTED BY: (L) C kp _4 EMPLOYEE M C)3 Z4 DATE: 6 D,L ASSIGNED TO: �Q t r,v✓, EMPLOYEE M SW DATE: D Date Service Completed (if already completed): SERVICE CODE: S-ZZ_ PIE: 2-f�.p/ Fee Amount: / �(c. Amount Paid �.) Payment Date 6 0 Payment Type Invoice# Check# (,3(� Received By. EHD 48-02-025 SR FORM(Golden Rod)