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SAN JOAQUIIPUNTY ENVIRONMENTAL HEALTH OARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID # CHECK if BILLING ADDRESS SERVICE REQUEST # 64 5 J)) 5/ -ANG t iL i N D �-Sp-o S -7 r OWNER / OPERATOR(// `�L N E/VLE /tiL�-�� r• �C. 9;� 2 %D `; (./� ti�7 CHECK if BILLING ADDRESS J FACILITY NAME 626L Z 7c) Sq --l7 FAX# (Y&L3) SITE ADDRESS r ig CITY r f c A ` c� 1-14A4 Meg- L)v�v� zip 7 r q / C7 / s7zt- -rL,w `� - c� �L Street Number Direction Street Name Payment Date Ci Zi Code HOME or MAILING ADDRESS (If Different from Site Address) , c #s b Z� Zio3 L'. ViNa v Street Number Street Name Street CITY STATE zip. 54AJ / O 95iY 8 3 PHONE #1 EXT. ('516) 26,7- DZ01 APN # I 08T.- IRV- 3o LAND USE APPLICATION # PHONE #2 EXT. BOS DISTRICT 2— LOCATION C CONTRACTOR / SERVICE REOUESTOR REQUESTOR Alea/ � &/M LAS7 P-7 t �6 1c f CHECK if BILLING ADDRESS BUSINESS NAME b�Ea 17A Uaiue.O�C rNTf7ZS •dam f6AJSOP= //V AO I' NpCO Ptctit T4/V/e-S A<SO PHONE # 1 Ex,. 370- 380 C) HOME or MAILING ADDRESS -2519 O(/WrKC A) DATE: p 1oei 0,�-s FAX# (Y&L3) 37Z _9 7(,-. CITY r f c A ` c� STATE C-4 zip 7 r q / C7 / 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,and FEDERAL laws. APPLICANT'S SIGNATURE: STAT/',,-_ DATE: PROPERTY/ BUSINESS OWNER 11 OPERATOR /MANAGER ❑ OTHER AUTHORIZED AGENT C��NTic iD�' If APPLIC NT 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 propigi�6 he above site address, hereby authorize the release of any and all results, geotechnical data and/or environmennt information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and atis provided to me or my representative. TYPE OF SERVICE REQUESTED: LAS7 P-7 t �6 1c f COMMENTS: /� en��E& X1511nJG /CE4" /Lu S --- 0 Uaiue.O�C rNTf7ZS •dam f6AJSOP= //V AO I' NpCO Ptctit T4/V/e-S A<SO ACCEPTED BY: ou t Ur—, V-4 EMPLOYEE #: Z DATE: p 1oei 0,�-s ASSIGNED TO: _A EMPLOYEE #: tr !. 2 i DATE: CI` Date Service Completed (if already completed): SERVICE CODE: ,?,f P 1 E: Fee Amount: 3 � Amount Paid 5 Payment Date RVL, IO Payment Type �� Invoice # , c #s b Z� Received By: G- o SNC EHD 48-02-025 REVISED 11/17/2003 SR FORM (Golden Rod) 0. F0