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I,� SAN JOAQ*COUNTY ENVIRONMENTAL HEA* DEPARTMENT SERVICE REQUEST f Business or Property FACILITY ID # SERVICE REQUEST # Z_ -t- N l L C• A S C 1' r ra t= PHONE# EXT. 9t6 1004 3F4 0 R / OPERATOR FAX# (yt6)3�3- lf�L 2 V 114- S T O P � A R K E 1 -T S r 37A(C CHECK If BILLING ADDRESS NAME QVtI� STOP /y� HT1'iq IN h CO MFUN )DRESS p (�l%EST LA1,LE- STOCL4T-0nd QSZ td t Z Street Number Direction DATE: -7 / -7 f 0 S Street Name Ci Zi Code Ir MAILING ADDRESS (If Different from Site Address) Fee Amount: E re -(L P M (T E S T2 E PT" 415-6 Street Number Street Name F►Z E VA 0 A -T STATE C A ZIP g Vr3 8 I� EXT. APN # LAND USE APPLICATION # 8S0 0 12 ExT. ) BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR '/(/' ' ^,� t C � A I- L � , W /A L-1 O . N I CHECK if BILLING ADDRESS BUSINESS NAME WALTO� Et-c(Z., I- ERR -L(k, .�Kc_ PHONE# EXT. 9t6 HOME or or MAILING ADDRESS -0• $o1C /025— Fp FAX# (yt6)3�3- lf�L CITY I t I XC Q. A VA E 9-.x,0 STATE C A 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 a FE laws. 0 APPLICANT'S SIGNATURE: DATE: T PROPERTY/ BUSINESS OWNER❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT M TEs -ro'(4 (^Q atiTt2 f}tii b/L 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: JZEll l F—W 1 /J . COMMENTS: Fp HT1'iq IN h CO MFUN p ACCEPTED BY: 0 UL V E( EMPLOYEE #: �) 3 Z� DATE: A� 4S ASSIGNED TO: km I C 4 E L L E G E EMPLOYEE #: DATE: -7 / -7 f 0 S Date Service Completed (if already completed): SERVICE CODE: P / E: ;L? . c� Fee Amount: Amount Paid a 2 Payment Date D !� Payment Type Invoice # Check # Received By: EHD 48-02-025 SR FORM (Golden Rod)