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SAN JOAQUIN W Ty ENVIRONMENTAL HEALTH%rARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID# SERVICE REQUEST# AJC -�A c 1`T� 15A 006) 00-7 Z_ OWNER/OPERATOR PILDT — j' ( A Je L Ct ja&!6 f `L �6 CHECK if BILLING ADDRESS FACILITY NAME l f C � C �� L L / ' SITE ADDRESS'l..V \J l�ll K U� d (� ll.....SIZ�( (�c, IQ52 �P Street Number I Direction Street Nam City Zip Code HOME or MAILING ADDRESS (if Different from Site Address) �`��"`---��o�-0AM6 /20 A (� �lf�(�P} !K-(�P"`✓ Str et Number Street Name CITY V L L E r STAT ZIP 3-19 Dry PHONE#1 EXT. APN# LAND USE APPLICATION# PHONE#2 EXT. BOS DISTRICT LOCATION CODE I L4 ( % il CONTRACTOR / SERVICE REQUESTOR REQUESTOR 6-12ou� I y� ^ CHECK If BILLING ADDRESS BUSINESS NAME J\( I �C' PHS E#An rg 9 -7Z�5 HOME Or MAILING ADDRESS LUCAS &00- ( ) 404 j®3C)C) CITY 2ayvc,-) U (� ��D�l l STATE CA ZIP /3 2. 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 application and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes,Stan ar ,STATE a d FEDERAL laws. APPLICANT'S SIGNATURE: / DATE: PROPERTY/BUSINESS OWNERO OPERATOR/MAN GER ❑ OTHER AUTHORIZED AGENT O ii If APPLICANT is not L 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: ` .k - T COMMENTS: �, r---6A j3CJ i 6r�� G J�CV -C tf e-�e— ci.c 4 11.1 JUL rveo 3 20f6 ACCEPTED BY: J1r EMPLOYEE#: DATE: H / ASSIGNED TO: � EMPLOYEE#: DATE: J J 1 y Date Service Completed If already completed): SERVICE CODE: P/E: / r' Fee Amount: i)., �I Amount Pap Payment Date 7/3 Payment Type Invoice# Check# d !3 Received By: EHD 48-02-025 SR FORM(Golden Rod) REVISED 11/17/2003