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SAN JOAQU 7,0UNTY ENVIRONMENTAL HEALTH ''ARTMENT SERVICE REQUEST Type of Business or Property FDd 71-1ek FACILITY ID # SERVICE REQUEST # sc_00.,(A,„--)_-c-A OWNER! OPERATOR if, L /5 /20cpt /7 till / C ./0 CHECK if BILLING ADDRESS c FACILITY NAME .7X/Ri9/94//zipAM A/Ala SITE ADDRESS 1J / . /1/7 Street Number J1 J) Direction ‘f /1 i ix J17(f Street ame 1Y-oe04 itv qi-ve Zip Code HOME or MAILING ADDRESS (If Different from Site Address) v y 1/- Street Number ii4e kok /fre /g. treet ame CITY 61N/ STATE a ZIP PHONE #1 EXT. 2 ? 17/ APN # LAND USE APPLICATION # PHONE #2 ../XT• idg i) ( ) BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR # - n eP Fe- /L-0. M 71Z1 CHECK if BILLING ADDRESS 13 BUSINESS NAME -1/9/7 /4//il „INA, piim,,,,a PHONE ( 4') _ z/2QVIT HOME or MAiLiNG ADDRESS /k) 9 igi /,,,,. 2,1,i ,, .„/, FAX # ( ) CITY 6&74- STATE ZIP 95- g ____ 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 t work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, Standards, dr/ST2 T ndF_EDE aws. APPLICANT'S SIGNATURE: z PROPERTY / BUSINESS OWN PERATOR MANAGER 0 OTHER AUTHORIZED AGENT 0 II.APPLICANT is not the BILLING PARTY, proof of authorization to sign is required Title AUTI1ORIZATION 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 provided to me or my representative. TYPE OF SERVICE REQUESTED: fig YM4 7* COMMENTS: V I E0 1414 R 3 0 ;MA 8461a0A ...sic(' ki&EA/V/po QUIIV I-, —,..,41. 7.,...; • otvms, ,-. otiN ,.,„ ACCEPTED BY: EMPLOYEE #: DATE: ,ricNr. ASSIGNED TO: j7 0 lir ,,t ,t4 , EMPLOYEE #: DATE: -'. _ 3t, Date Service Completed (if already completed): SERVICE CODE: 05,2_3 j PIE: 4 0/ Fee Amount: #0 II cf./2 , 06 _ r.i•- Amount Palvi t , Payment Date — r y / Received By:di;" Payment Type i 1 Invoice # Check # tr) 7 -v s _..-3 ,..,_. DATE: EHD 48-02-025 REVISED 11/17/2003 - SR FORM (Golden Rod)