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SAN JOAQUIN C OUNTY ENVIRONMENTAL HEALTH DEP RTMENT SERVICE REQUEST Type of Business or Property BUSINESS NAME Ca l'e f r l v F a/ �tN� /A/C FACILITY ID # HOME or MNG A RESS 4 � �� / f _rP� t r - 96ac SERVICE REQUEST # &tqlL / ToJf_ l r> �� LBS ?7 3 0 11 saw(,'4S,07 OWNER/ OPERATOR 1/a T � a � L / /C/ �J �� _7/V (�t�/ CHECK If BILLING ADDRESS FACILITY NAME ^ � V O P 1 E: Fee Amount: 3 0 SITEADDRESS/ � Payment Date �� T- / f� Payment Payment Type �" 1�Ci Street Number Direction treetNGame Zi Code HOME or MAILING ADDRESS D' Brent from Site Address) ) j(if ! / J t Street Number Street Name CITY ,CrSTATE ail/ C ZIP n `� PHONE #1 EXT. APN # LAND USE APPLICATION # 4-R ►Ssl?. SS -3 3 C o30• l 2 PHONE #2 ( ) EXT. BIDS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR 7 Sr 1 G G _{ CHECK if BILLING ADDRESS Ef ( BUSINESS NAME Ca l'e f r l v F a/ �tN� /A/C PHONE# EXT. 5?02 - y 7-7 HOME or MNG A RESS 4 � �� / f _rP� t r - 96ac FAx # ( ) et/y) I -e -V CITY STATE ZIP 6>A 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 TATE and 17E L la s. APPLICANT'S SIGNATURE: DATE'��P PROPERTY / BUSINESS OWNER 1:1OP TOR / MANAGER ❑ THER AUTHORIZED AGENT (�% �/ 7 /y C ! `% V, 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 atl�dAat�Ilesatne time it is provided to me or my representative. r n c tv F TYPE OF SERVICE REQUESTED: COMMENTS: MAR 0 SAN JOAQUIN COdJNTY ENY1ROHMENTAL HEALTH DEPARTMENT ACCEPTED BY: L0 EMPLOYEE #: S DATE: 3 _� I 2— ASSIGNED ASSIGNED TO: EMPLOYEE #: 3 (- DATE: 3 5 I 2— Date Service Completed (if already completed): Date SERVA CODE: 1 P 1 E: Fee Amount: 3 0 Amount Paid � Payment Date / -)— Payment Payment Type �" Invoice # Check # '9570 Received By: ,E EHD 48-02-025 SR FORM (Golden Rod) REVISED 11/17/2003 QU �__