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SAN JOAQUSOUNTY ENVIRONMENTAL HEALTH OARTMENT SERVICE REQUEST Type of Business or Property C� cis S+off- &I / "a Mart FACILITY ID # 6t?It0 SERVICE REQUEST # OWNER / OPERATOR � —_8 `� � '^ Cl c CHECK if BILLING ADDRESS FACILITY NAME c ` J " to u ULA Si.(,�c I�c(/e/ lt V —Nip SITE ADDRESS 1,4q q (lumber Street umber Direction �-j U 0 Street Name IJV CI Code HOME or MAILING ADDRESS (If Different from Site Address) Street Number Street Name CITY STATE ZIP PHONE #1 ExT. (coq) 3 9 - S-3 h APN # Payment Type LAND USE APPLICATION # PHONE #2 ExT• BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR` BILLING CHECK if BILLING ADDRESS BUSINESS NAME C1 try `y „. 1 �'�� S✓�SL� kS � oLV e IC &z cL C✓ EMPLOYEE #: P'!S PHONE oc t z,3 — ExT. HOME or MAILING ADDRESS 61b Ou vtvl AV--- FAX X# (41t�) Date Service Completed (if already completed): CITY 5C. V t0S-c- STATE CN zip 9100- SIt 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 and FEDERAL laws. -4CYSf v' i (e Ra4t ', ►S4 -V APPLICANT'S SIGNATURE: `%IIp,41 toot Ll �=2 �L �t � i.� DATE: PROPERTY / BUSINESS OWNER ❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT Mf� If APPLICANT is not the BILLnyGPARTY, 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: COMMENTS: vk ry"(+ /i Q�-etk _U r (a-t1L ACCEPTED BY: Lvcr-s &z cL C✓ EMPLOYEE #: P'!S n &e, F-ry a vEc FEE 2 1 2006 SAN JOAQUIN CO NTA DATEN�7ME NT ASSIGNED TO: `,AC_C1r=, EMPLOYEE M %4,9S DATE: V j-- 2A - Oj:' Date Service Completed (if already completed): SERVICE CODE: P i E: 26p8 Fee Amount: 9 Amount Paid Payment Date a. 12,k 166 Payment Type Invoice # Check # 2,(?, Received By: EHD 48-02-025 SR FORM (Golden Rod) REVISED 11/17/2003