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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property G l`6—r-d SetlS0I2— LI X21 f0N t.) FrJ FACILITY ID # SERVICE REQUEST # ) . 5� �^�G{ tG oo 6 e7 OWNER /OPERATOR A.1NnO3 NinovoP NVS CHECK if BILLING ADDRESS FACILITY NAME GIS o p /-� �^ f "� 3 g t� Ai J 1, 1 1Ll f � ' SITE ADDRESS 1 qq l E. �� � 15266 . ` Street Number Direction Street Name OAT' 10 ZQ Ci Zio Code HOME or MAILING ADDRESS (If Different from Site Address) EMPLOYEE #: DATE: Date Service Completed (if already completed): Street Number SERVICE CODE: �(� Street Name CITY -� q p STATE ZIP PHONE #1 EXT. APN # Invoice # LAND USE APPLICATION # PHONE #2 ExT. BOS DISTRICT LOCATION CODE PnNTR AC'TC1R / .QF.RVTCF.. RF.01TF.4T0R REQUESTOR ` CHECK if BILLING ADDRESS BUSINESS NAMEEUTEMWNJERTIR�- PHO E#' s HOME or MAILING ADDRESSFAX # 256Wl WI Q (261 `W -C CITY Zqbc6,\ 1 V nri STATE ZIP 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: 4� DATE: PROPERTY/ BUSINESS OWNER❑ OPERATOR/ MANAGER ❑. OTHER AUTHORIZED AGENT GGG ��` 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: eC PLJ9Qt -}OT W 1d 0 G l`6—r-d SetlS0I2— LI X21 f0N t.) FrJ COMMENTS: ) . 5� �^�G{ tG 1HVd30 H11V3H 1V1N3WOt1IAN3 A.1NnO3 NinovoP NVS MR f 9 -100 03AI333EI ACCEPTED BY: (�`V-� �` EMPLOYEE #: OAT' 10 ZQ ASSIGNED TO: k\4- &W—r-Z> EMPLOYEE #: DATE: Date Service Completed (if already completed): SERVICE CODE: �(� PIE: 23a� Fee Amount: -� q p Amount Paid 39(D ,tom Payment Date tp 2� Payment Type Invoice # Check # `gyp Received B . EHD 48-02-025 SFS FOf��lvl ( oldO`ri`Roci)' '' REVISED 11/17/2003