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i ~ SAN JOAQ UIN COUNTY ENVIRONMENTAL HEALTHfizPARTMENT SERVICE REQUEST Type of Business or Property �^ L �O 14 �/(/ H FACILITY ID # CHECK if BILLING ADDRESS LQJ SERVICE REQUEST # RETA,tL PHONE # 916 ExT' 3 a 3 - H 3 -%-- HOME or MAILING ADDRESSFAX 'P_ 0 • OWNER / OPERATOR ACCEPTED BY: c. t_ i �/ t✓ c CHECK if BILLING ADDRESS❑ O4 FAmE CITY W C 1--a EMPLOYEE #: 7S FACILITY NAME 0 I: A rL E W A -m IL F --T- � 3 .9- SITE ADDRESS (L A L r ^IF- R D' Fee Amount: �� 0 ;- T R A C Y 9S 3 ('o is Street Number Direction Street Name Invoice # Ci Zi Code HOME or MAILING ADDRESS (If Different from Site Address) 1 K t K C. S T Street Number Street Name --ZS-06q CITY I' p-1 W , , `A M ti STATE CAZIP 9 y.5— , / C Y PHONE #1 APN # LAND USE APPLICATION # PHONE #2 E)cT. BOS DISTRICT LOCATION CODE il ( ) 15 C ! L4- CnNTR ACTOR / SFRVICE REOUESTOR REQUESTOR 1 C A, l L v/� �^ L �O 14 �/(/ H COMMENTS: CHECK if BILLING ADDRESS LQJ BUSINESS NAME 1A/ A L r O t•[ � t' PHONE # 916 ExT' 3 a 3 - H 3 -%-- HOME or MAILING ADDRESSFAX 'P_ 0 • 'j3 X / D Z S" ACCEPTED BY: c. t_ i �/ t✓ c # (9/6 ) 3 -+3 - / r + 7 -- CITY W C 1--a EMPLOYEE #: 7S STATE CA ZIP C"5'6 a 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!Z99 e work to be erformed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, Standlaws. APPLICANT'S SIGNATURE: DATE: 1 L�I S- �O 6 PROPERTY/ BUSiNESS OWNER❑ ❑ OTHER AUTHORIZED AGENT A C 0 AT R A LTO I 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 swe time it is provided to me or my representative.�� TYPE OF SERVICE REQUESTED: ( A �c Z E �t E tnl i�(S ,2c� F� COMMENTS: SPPN �� R NM ��MEN� H�LZN MEPP ACCEPTED BY: c. t_ i �/ t✓ c EMPLOYEE #: 3'2 l DATE: l L — Q (v ASSIGNED TO:N fT EMPLOYEE #: 7S DATE: Date Service Completed (if already completed): SERVICE CODE: [ P /'E: Fee Amount: �� 0 ;- Amount Paid Payment Date 102 P -( p Payment Type Invoice # Check #� eceived By: EHD 48-02-025 FORM (Golden Rod) REVISED 11/17/2003