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SAN JOAQUOOUNTY ENVIRONMENTAL HEALTROARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID # S VICE REQUEST # CO,57-77/ OWNER / OPERATOR _ j v'&4 4 a CHECK If BILLING ADDRESS FACILITY NAME No BUSINESS NAME � Pe ��1�� SITE ADDRESS Z� 7 Street Number I Direction Street Name HOME or MAILING ADDRESS ► 7 0 S4 Cit Zip Code ROME or MAILING ADDRESS (If Different from Site Address) Street Number CITY Street Name CITY STATE ZIP PHONE #1 EXT. (-zl)r,) q3 2 -130"7 APN # LAND USE APPLICATION # PHONE #2 EXT. ( ) BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REOUESTOR REQUESTOR J ��L� I CHECK If BILLING ADDRESS 4 k e C' V e J v� BUSINESS NAME � Pe ��1�� PHONE # �2- EXT. 2- -q HOME or MAILING ADDRESS ► 7 0 S4 FAX # (yZ S) `% 2 - F 3 ,� z CITY STATE 6A ZIP '-:1 q 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 will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, Standards, ST TE and FEDERAL law . / l of APPLICANT'S SIGNATURE: &4ti ' C — DATE: PROPERTY / BUSINESS OWNER❑ OPERATOR MANAGER ❑ OTHER AUTHORIZED AGENT If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required Title AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, 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. ...,,..inAI=NT TYPE OF SERVICE REQUESTED: COMMENTS: LAST- l -e -�r'c) (, -� � 9 JUL ENVIRONMENT!F WEPAATMtlmr- C (� PERMIT/SERA ACCEPTED BY: EMPLOYEE #: / T DATE: it ASSIGNED TO:EMPLOYEE #: LLL CCC DATE: tJ Date Service Completed (if already completed): SERVICE CODE: P I E: Fee Amount: S o Amount Paid ` S -- I Payment Date -116116,1 Payment Type ✓ Invoice # Check # -� ,I' -I -? f. I Received By: EHD 48-02-025 REVISED 11/17/2003 SR FORM (Golden Rod)