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3AN JOAQUIN ' ' UIN 1 Y L' N VIRUNWILN IAL riLALlow AK71V1LN 1 SERVICE REQUEST Type of Busin s or Property FACILITY ID # SERVICE REQUEST # HOME or MAILING ADDRESS I,�lJ o66M Lk 1 O' /91 FAx I -Q F/4em3C.,©6 5Re633�V'6 OWAER / OPERATOR MAY 12003 CHECK If BILLING ADDRESS SAN JOAQUIN COUNTY FACILITY NAME ayn,19/w PUBLIC HEALTH SERVICES ENVIRONVFNTA.1 HFAI TH DIVISION APPROVED BY: SITE ADDRES$�1 I / 16) t d ` 2 2 9'2-- DATE: ASSIGNED TO: Street Number Direction �/ Street Name DATE: -� d Zi Code HOME Or A ING ADDRESS If Differ e t from Af Address) Amount Paid �(�� ev I l Street Number Payment Type Street Name CITY �y✓ Check # 2 STATE ZI� PHON 1 EXT.APN ( 8� ) 7.79 -W # LAND USE APPLICATION # PHONE #2 EXT. B DISTRICT LOCATION CODE CONTRACTOR / SERVICE RE, QUESTOR REQUEST/ ' l // QV J�) CHECK If BILLING ADDRESS BUSINESS NAME 1 r y�ld . - p �,t.n % t �XT. 'Z C (L� HOME or MAILING ADDRESS I,�lJ o66M Lk 1 O' /91 FAx I -Q CITY r J T E ZIP^� 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, Standard , ATE and FEDERAL laws. APPLICANT'S SIGNATURE: DATE: /-/ PROPERTY / BUSINESS OWNER ❑ OPERATOR / MANAGER ❑ OTHER AUTHORIZED AGENT 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 envirotirnental/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: T COMMENTS: RECEIVED MAY 12003 SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONVFNTA.1 HFAI TH DIVISION APPROVED BY: EMPLOYEE #: 2 2 9'2-- DATE: ASSIGNED TO: EMPLOY DATE: -� Date Service Completed (if already completed): SERVICE CODE: / 'Yr P 1 E:-�2 30 8 Fee Amount: 2 6.7 "0 Amount Paid �(�� ev Payment Date Payment Type Invoice # Check # 2 Received By: EHD 48-01-025 SERVICE REQUEST FORM REVISED 6-5-02 IW A