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SAN JOAQIWOUNTY ENVIRONMENTAL HEALTAPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID # c ,,,- BUSINESS NAME , 0-"';C C ON Sf�G V l SERVICE REQUEST # Ca, t4"5 szT� o N' EXT. o� �3 0 j ASSIGNED TO: 1 1IC-- A,/, 3 ° C)o S (o c OWNER / OPERATOR y C("e_v �� U S Pr CHECK If BILLING ADDRESS❑ FACILITY NAME (i, t �1Cj�.'l'.i-I v, I Fee Amount: 3 i t Amount Paid 31 S �- SITE ADDRESS r'1 S J'— � Payment Type t/ �4i��y '��U� Check # 2 -S --rirc �r y 7 q s-3.7/' l Street Number Direction fleet N me Ci i Codle!'� HOME or MAILING ADDRESS (If Different from Site Address) Street Number Street Name CITY STATE ZIP PHONE #1 EXT. APN # LAND USE APPLICATION # l 1 2 y 2- C"- 2-`j PHONEY EXT. BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR OL `1 CHECK If BILLING ADDRESS c ,,,- BUSINESS NAME , 0-"';C C ON Sf�G V l LLe PHONE EXT. o� �3 0 HOME or MAILING ADDRESS to �0 �,w'l �� ASSIGNED TO: 1 1IC-- A,/, FAx ,jog, �(a-- /Oak CITY C54 -C STATE eA zip Q S 1 t 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. J APPLICANT'S SIGNATURE: h{�� t> � �. tiL� tom' DATE: a/Sl as Ip (� PROPERTY / BUSINESS OWNER 13 OPERATOR/ MANAGER [3 OTHER AUTHORIZED AGENT �n O -C- �.Q�utt -C-e t 1Z 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. (tet S T tP—� ' e F- t T TYPE OF SERVICE REQUESTED: U'ST i u C- (c -N r'AYIV� �y �/ �j- COMMENTS: r'C 4 4L1. Tw L `Cq c%�C�,�f-a L �� L(7l � y ` CR �� c D FEBI ' 0 61009 SAN HEgLAM1}t p PMEIV7�N7Y '�TMCNT ACCEPTED BY: I✓} (, I v� I / ,� EMPLOYEE M U^Z / DATE: 2(� c ASSIGNED TO: 1 1IC-- A,/, EMPLOYEE M L f/ "� DATE: '-7/ � / 7r - Date Service Completed (if alr ady completed): Date SERVICE CODE: / 1f S% P I E: .. Fee Amount: 3 i t Amount Paid 31 S �- Payment Date Payment Type t/ Invoice # Check # 2 -S Received By: wstl EHD 48-02-025 SR FORM (Golden Rod) REVISED 11/17/2003