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JAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property CHECK If BILLING ADDRESS FACILITY # SERVICE REQUEST # BUSINESS NAME ^ ` C OOI. �ID �2- & ` 0 SJZOVF (0 ((f y OWNER 1 OPERATOR 201 Yr1'4B o0 HOME or MAILING ADDRESS CHECK If BILLING ADDRESS FAX # L• FACILITY NAME (Zov oN - (a&o4 SITE ADDRESS ..1611 STATE C A ZIP n W Z 3 Street Number Direction Street Name city Zip Code HOME or MAILING ADDRESS (If Different from Site Address) ^� 1 tLi. P".4 SERVICE CODE: Street Number Street Name CITY STATE ZIP 7 A 9601,0-7 PHONE iii E'. Invoice # APN# LAND USE APPLICATION# c 2aS) Sao -ysv3 o—t 12cxooLk PHONE #2 EXT. BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR , REQUESTOR II C � CHECK If BILLING ADDRESS l.pN A� l'Ti U� • v BUSINESS NAME ^ ` C w- @R— PHONE# E�' RECEIVED 201 Yr1'4B o0 HOME or MAILING ADDRESS FAX # 1 116 t ct, ACCEPTED BY: p t f� (Zov oN - (a&o4 CITY A-M-CGKL- STATE C A ZIP n W Z 3 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. APPLICANT'S SIGNATURE: /�j•�„•,,;s, �%, DATE: t"�+4 /%7a -o9 t PROPERTY/ BUSINESS OWNER❑ OPERATOR/ MANAGER OTHER AUTHORIZED AGENT 11 IfAPPL/CANT is not the BlLLLVGPARTY 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: G 1..( E 4-C- j C-O.VS LL L7l4 -1-7 U COMMENTS: {)rt 54_C.a�-�yy� af•.bW,•n •r Q,�u.�-Q-y_Qr- (/ v t� PAYMENT w- @R— RECEIVED JAN 29 20 ".JOAQUIN ACCEPTED BY: p t f� EMPLOYEE#: O3 L ni H Dl ASSIGNED TO: S Lf7 EMPLOYEE #: 0 q DATE: Date Service Completed (if already completed): SERVICE CODE: PIE: 3 Fee Amount: (U S, r%) Amount Paid Payment Date g 7 Payment Type Invoice # Check # I iReceivild By: EHD 48-02-025 ' f ' �'( 0l`.8't;'n"Fto) ' REVISED 11/17/2003