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SAN .TOAQ UOCOUNTY ENVIRONMENTAL HEALTH DtPARTMENT SERVICE REQUEST Type of Business or Property CHECK if BILLING ADDRESS FACILITY ID # SERVICE REQUEST # PHONE # ExT. '}o ~ 1 -11.1117 OWNER I OPERATOR P S1t Q _ Q n T 64 e CO ��,1` \ b� �t -r q- T- Ca (i f _n I CHECK if BILLING ADDRESS Ct IT .iD� `.1 FACILITY NAME 6-11-1 u EOQ- STATECAZIP 9+954 SITE ADDRESS '345 I Nkf+l-fh a rF.RTm et47 n �"2fc �l✓) S6ct Stec 6>-% ASSIGNED TO: Street Number Direction Date Service Completed (if alreaay completed): t Name Fee Amount: Amount Paid Zip Code HOME or MAILING ADDRESS (If Different from Site Address) %-L,00 Camino '3 E00 ux 10 AA Payment Type Street Number Check # 3331 treat Name CITY Sal., K n Rc�1 ST/,TE Zip 14,573 PHONE #1 E'�T (214) 464-55-i 1 APN # (39- Ro-o� LAND USE APPLICATION # PHONE #2 ExT• l 1 BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR Lkri� s CHECK if BILLING ADDRESS BUSINESS NAME S l;s� n wa %fit c.�,! r�L . PHONE # ExT. '}o ~ 1 HOME or MAILING ADDRESS 3? W. M �� i . Sv, � FAX# (;ZI ► -Y,5- -IN d CITY Peka kvm 1 STATECAZIP 9+954 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, S TE an L laws. AA APPLICANT'S SIGNATURE: 7� DATE: 04- 1,661ac) I C PROPERTY / BUSINESS OWNER ❑ OPERATOR/ MANAGER 0 - OTHER AUTHORIZED AGENT 17 l -D -1 t -rt If APPLICANT is not 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 available and at the same time it is provided to me or my representative. TYPE OF SERVICE REQUESTED: COMMENTS: Nkf+l-fh a rF.RTm et47 ACCEPTED BY: L..� i �� EMPLOYEE #: ASSIGNED TO: EMPLOYEE #: Date Service Completed (if alreaay completed): SER cE ODE: P 1 E: �j 300 Fee Amount: Amount Paid Payment Date ux 10 AA Payment Type Invoice # Check # 3331 Received'By: EHD 48-02-025 REVISED 11/17/2003 SR FORM (Golden Rod)