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y SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property V -J'f 0-1—c-- l.•(' BU SS NAM FACILITY ID # SERVICE REQUEST # O-a G_/q 10-,P5 ✓,CJ ecwv1ar V- FAX# 11 58008 130 9 OWNER / OLiu,ERATOR 2G t � I (�, ( 'T /1 tl L l/�- CHECK If BILLING A KESS FACILITY NAME 1 l(/ 1 PIE. f 0Q 1 d Fee Amount: 5 a Amount Paid SITE ADDRESS Payment Date L �GI V t/� Payment Type (1 /,� 0 Street Number rectlo t/ l StreetNameCi Received By: Zi Cotle HOME or MAILING ADDRESS (If Different]j fl1r�ompSiteLAddmss) 01 �l T Street Number Street Name CITY/�j C S � R STATE ZIP _ S� PHHONE#1 EXT. APN # LAND USE APPLICATION # (UCI `-1-7Le — 12 $s PHONE #2 Exr. BOS DISTRICT LOCATION CODE (9-M) U —O 2S CONTRACTOR / SERVICE REQUESTOR CHECK If BILLING ADDRESS RE risTeIQ V -J'f 0-1—c-- l.•(' BU SS NAM PHONE # Ext. M --u L O-a G_/q 10-,P5 ✓,CJ HOME Or MAI LIN ADDRES FAX# `10 ( ) CITY ` 1 STATEry) ZIP Gi 10 BILLING ACKNOWLEDGEMENT: 1, 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. 1 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 TATE td EDERAL laws. � APPLICANT'S SIGNATURE,: DATE: 1()12,5119 PROPERTY/ BUSINESS OWNER�/1J E TOR/MAN.4CER❑ OTHE AUHORIZED AGENT 13 IfAPPLICANT is not file BIL G PARTY proof of authorization to sign is required Tirle AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, 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. dA, TYPE OF SERVICE REQUESTED: COMMENTS: OCT 1 S 2049 Jn.__ ACCEPTED BY: V tl G yedra Z-1 EMPLOYEE #: DATE: O-a G_/q 10-,P5 ✓,CJ ASSIGNED TO: Fa h m EMPLOYEE #: DATE: /O _ a r I ("/ Date Service Completed (if air dyCompleted): SERVICE CODE: PIE. f 0Q 1 d Fee Amount: 5 a Amount Paid �� ; Payment Date O Payment Type (1 /,� Invoice # Check # I Received By: EHD 48-02-025 REVISED 11/17/2003 SR FORM (Golden Rod)