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SAN JOAQUIN UNTY ENVIRONMENTAL HEALTHJEPARTMENT SERVICE REQUEST Type of Business or Property '"- `'�'';�' c'" ` FACILITY ID # SERVICE REQUEST # BUSINESS NAME f _� 0Q)I 0 �- ca -CK HOME Or MAILING ADDRESS)-� S W \ W 0. i(Y1 O C \ l7 to 6 q6 2— OWNER/ OPERATOR CHECK BILLING ADDRESS ZIP 9 05— If „ � L � ` T FACILITY NAME ` -110 v SITE ADDRESS I CI 3 S � `� (� v �}c� CHIC vo r -,Street �S2 ISS Number Direction 6 03. Street Name Ci Zi Code HOME or MAILING ADDRESS (If Different from Site Address) y S b , YN ! e �• P t`. S �SA C e Q �- Fee Amount: '�� Street Number Street Name CITYSTATE e �M o r) 1- ZIP 9 + t S � `i PONE #1 EXT. 912. APN # Received By: LAND USE APPLICATION # (go) PHONE #2 EXT. BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR w Q C,,(--\' 4Z_ ` z �� r ,'�` CHECK If BILLING ADDRESS Rf BUSINESS NAME PHONE# (.209) EXT. `1161 - b 3 3 HOME Or MAILING ADDRESS)-� S W \ W 0. i(Y1 O C \ l7 0-09) q6 2— CITY C . -Oc \vo STATE CITY ne-A ZIP 9 05— 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, STATE and FEDERAL laws. APPLICANT'S SIGNATURE: (\� DATE: 1 19 0 3 PROPERTY/ BUSINESS OWNER ❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT -W OC-lA If APPLICANT is n 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 availablet",p the same time it is provided to me or my representative. pAi2GIVED TYPE OF SERVICE REQUESTED: t�T n r ,'�` COMMENTS: D GOTV SAN JOAOVIN HEATH DEPAR7MEhIT ACCEPTED BY: / V EMPLOYEE #: ` (�lL' DATE: 02) ASSIGNED TO: S �A.f EMPLOYEE #:3 DATE: 6 03. Date Service Completed (if already completed): SERVICE CODE: �C�� P 1 E. Fee Amount: '�� Amount Paid 4 -).,7,j.L Payment Date ` -.Z-q/p3 Payment Type ✓' Invoice # Check # '7R3 Received By: EHD 48-02-025 SR FORM (Golden REVISED 11/17/2003