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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID # SERVICE REQUEST # res s Xk-110 Ce 3 �wo,59 916 OWNER/ OPERATOR 41M-) (—(2 �1 CHECK If BILLING ADDRESS FACILITY NAME ^ (Lco UP) SITE ADDRESS %90b � 5 -oC- 95 ZOY Street Number Direction Street Name City Zi Code HOME Or MAILING ADDRESS (If Different from Site Address) ACCEPTED BY: Street Number Street Name CITY STATE ZIP PHONE #1 EXT. APN # LAND USE APPLICATION # ( Zo-k) RS -7 Z-98-7 SERVICE CODE: PHONE #2 EXT. P 1 E: O BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR Y REQU STOR e- /� CHECK if BILLING ADDRESS I� BUSINESS WAME� (!` PHONE # Exr. HOME or MAILING ADDRESS FAX # ///C' w l� ,,,, Lo1� dl-� 3�- 3 (WIc?) 3 6r- c Sic 3 CITY 2-0 &U U&U STATE Cj4 ZIP C) 5 -Z�rl o 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, STATE and FEDERAL laws. APPLICANT'S SIGNATURE: DATE: -71ZJ1 /,J -,OF PROPERTY / BUSINESS OWNER ❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT Q�I1/LrL�� r/ii S /�" If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required i 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. n - TYPE OF SERVICE REQUESTED: I S, I r _ C COMMENTS: Sgly ?S I JUL 294#R �w D4N11Enr�(/ ENVIRONMENT HEALTEI. N ACCEPTED BY: EMPLOYEE #: / DATE: 7 t ASSIGNED TO: %� EMPLOYEE #: 23 DATE: Date Service Completed (if already completed: SERVICE CODE: / P 1 E: O Fee Amount: y Amount Paid 1 5 _ Payment Date (I 2� g Payment Type t� Invoice # Check # (� t g Received By:S EHD 48-02-025 SR FORM (Golden Rod) REVISED 11/17/2003 ✓T r,