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��'• '� S•i-"� 4 .'<<�t �t �Al�il©Ml, � ><)I .C:(JHPI#'Y LiVVIRUNn•IF;N'CA•L-�.�FA[�'FIi9ili:l'AR'PIYIEN'I' ; ,.�,":�;.";" SERVICE IZQUEST Type of Business or Property FACILITY ID t_F SERVICE REQUEST I —go oyu -� OWNER/OPERATOR CHECK if BALING ADDRESS D FAciLm NAME SITE ADDRESS Street Number Dkection N - Z Code HOME or MAILWG ADDRESS (If Different from Site Address) i i a" Street (refit Nine CITYLU May .ave expir OL'' ZIP PHONE illE'rT T PN N LAND bSE APP TION x PHONE 12 BOS DtsTPICTT OCATION COOE ( ) CONTRACTOR/ SERVICE REQUESTOR REQUESTOR CHECK If OILL G ADDRESS❑ BustNEss NAME PHONE Exr. HOME or MAILING ADDRESS FAX$ t4 Cmr STATE Zip BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of came, 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 JOAQuw COUNTY Ordinance Codes,Standards,STATE and FEDERAL laws. APPLICANT'S SIGNATURE: DATE: PROPERTY/BUSINESS OWNER❑ OPERATOR/DIANAGER ❑ OTHER AvniomzED AGENT❑ If APPLICANT is not the BILLING 84R17 proof of authorization to sign is required Title AUTHORIZATION TO RELEASE INFORMATION: When applicable, Ir 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 provided to me or my representative. yy TYPE OF SERVICE REQUESTED: J4 V i Lv ccG`C-L t:OttttENTs: V�� -•1 �.,,,.,y,� c��Y,--, � �j,e�,.� C 17� J U(S� Nov 2 4 2004 `d � � SAN JOA-00114 COUN1`I' FNVIRONNENTAL ACCEPTED BY: �l(,� V—��r�� /� EMPLOYEE#: I ( DATE:HE L- ASSIGNED TO: C S C L.' t (,J I EMPLOYEE#: 5 (f DATE: / Z <//O Date Service Completed (if already completed): SERVICE CODE: (�(� P 1 E 4 21; L. Fee Amount: -1 t^3 Amount Paid ; .- Payment Date Payment Type Invoice it Check# 1 t,�,� Received ByEHD . REV SED 1115 n 1001 �0 I/ SR FORM(Golden Rod) REVISED 1111712003 1` �v T'"