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SAN JOAQUI' 7OUNTY ENVIRONMENTAL HEALTT'-DEPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID# SERVICE REQUEST# A RILUL �A � Es/orv7-1S2ct, OWNER/OPERATOR CHECK If BILLING ADDRESS 1 /n R . D A k LJ/Al QV/'� N /;7R . A0 J- L t/,4C' FACILITY NAME SITE ADDRESS S�U rH STS 1'-Je4(,t L �S L,q LO/�/ 9�3t 0 6 4 2 Street Number Direction Street Name city 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# ( ) �g 6 - s"6 S o - a-7 /�', -o - 16 PHONE#2 ExT. BOS DISTRICT LOCATION CODE ( ) CONTRACTOR/ SERVICE REQUESTOR REQUESTOR G�f � CHECK If BILLING ADDRESS BUSINESS NAME PHONE# Exr' CONI ul� T A a-0-1403 HOME or MAILING ADDRESS FAX# F I3ox 3 714 c ) G -z5- CITY t-GG4 STATE CA ZIP t 9 / 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,YYE and F09RAL laws. APPLICANT'S SIGNATURE: DATE: PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTIIORIZED AGENT IfAPPLICANT is not the BILLING PARTY,proof of authorization to sign is required Title AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owof the property located at the above site address, hereby authorize the release of any and all �D =ENT chnical data and/or env Aae ite assessment information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH as soon as it is available andsame time it is provided to me or my representative. 1/ TYPE OF SERVICE REQUESTED: SD/, fu I TA_R/j l S Tu D — 0Fx PED l TES V(r W COMMENTS: ILI PAY KA NT RECEI ED �7s� g�9S AUG 5 20 -S N JOAQUIN COUNTY NVIRONMENTAL ACCEPTED BY: ( iv t B•HEALTH DEPAR I4IPNT LOYEE#: G,S Z DATE: gScS ASSIGNED TO: 1-4 ut C�t ti S EMPLOYEE#: g�l f DATE: � /S (C f C SERVICE CODE: 2 c', Date Service Completed (if already completed): / Fee Amount: �� - ._ 3 I v Amount Paid 3 Payment Date 8- P Payment Type / Invoice# Check# Received By: /C EHD 48-02-025 SR FORM(Golden Rod)/ REVISED 11/17/2003