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SAN JOAQU UNTY ENVIRONMENTAL HEAL' EPARTMENT SERVICE REC2UEST Type of Business or Property QFLd FACILITY ID # �- 000 3 Go SERVICE REQUEST # 0:35 3i3 OWNER / OPERATOR S O" JS S� CHECK if BILLING ADDRESS FACILITY NAME Yw I.J4\L f—r1 `=E M v t pp c (—%pQ ) SITE ADDRESS 1(„ (� Street Number t t f Direction fr Q m D✓I --- ® Street ame (_j ,� City Zip Code HOME or MAILING ADDRESS (If Different from Site Address) Street Number Street Name CITY SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES STATE ZIP PHONE #1 ( ) FXT• APN # LAND USE APPLICATION # PHONE #2 ( ) EXT. ASSIGNED TO: Q �� C -� BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR CHECK if BILLING ADDRESS UBNNFIL-0. IIIS- 4S- IQ QFLd BUSINESS NAME Q _..`. PHONE # EXT. J _ CO AACTe C. S O" JS S� HOME or MAILING ADDRESS FAx # I.J4\L f—r1 `=E M v t pp c (—%pQ ) CITY STATE Zip or) AL 't L` C -A C 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 FEDERAL laws. APPLICANT'S SIGNATURE: DATE: PROPERTY/ BUSINESS OWNER❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENTIR AG Q (� 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 same time it is provided to me or my representative. TYPE OF SERVICE REQUESTED: ; rC, rID fit PAYMENT COMMENTS: RECEIVED SEP 2 4 2003 SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION APPROVED BY: EMPLOYEE #:, "L"L� "L DATE: a ASSIGNED TO: Q �� C -� EMPLOYEE #:g S 7 3 DATE: 9-114-03 Date Service Completed (if already completed): SERVICE CODE: y� P I E: Z� o Fee Amount: �'� Amount Paid ?--- Payment DateLC9- ® 3 Payment Type Invoice # Check # 3 Received By: EHD 48-01-025 SERVICE REQUEST FORM REVISED 6-5-02