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SAN JOAQU_ �OUNTY ENVIRONMENTAL HEALTL EPARTMENT SERVICE REQUEST Type of Business or Property %� X L-=.2--s-0K�'J FACILITY ID � BUSINESS NAME,),) �,TL 5 (f I p SERVICE REQUEST ## OOeV OWNER/ OPERATOR / 6/Z ( (/ CHECK If BILLING ADDRESS /I FACILITY NAME f+" ✓VJ F9zJtn gelo -d�vI SITE ADDRESS (`✓ /_G ' 17 Street Numbe( DI Non /� C pi /,/irff /eD _ V Street ama EMPLOYEE #: C Catle HOME or MAILING ADDRESS (If Different from Site Address) SNeat Number Date Service Completed (If already completed): Street Name CITY STATE zip Ea'' PHONE #) q'51({J// APN # LAND USE APPLICATION # PHONE #2 ExT BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR / f� (///IG. / 1. � � J CHECK If BILLING ADDRESS� BUSINESS NAME,),) �,TL 5 (f PAYMENT �„ �D RECEIVE f�7��5, \�I Z 4 EC PHO E 1 3-7� EST. aIDOL , HOMEor MAILING ADDR ALL � F9zJtn gelo -d�vI CITU �/ ti - O STATE`((``!' ZIP 95 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, STA_TE and FEDERAL laws. APPLICANT'S SIGNATURE: DATE:^�_(//3 PROPERTY/ BUSINESS OWNER❑ OPERATOR/ EJ OTHER AUTHORIZED AGENT a/(aGJ/61-- IjAPPUCANT is not the BILLING PAR TP proof Of authorization to sign is required Titre 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. PD o t4s,0 4 Re*0 414 lP_F✓ CAFE ALA^) C1cEECr— TYPE OF SERVICE REQUESTED: LI N� [.✓ G '`/ COMMENTS: PAYMENT �„ �D RECEIVE f�7��5, \�I Z 4 EC DO j1lijl1 DI�� AUG 2G�1� " I- �JIJ QUCT G 4 SAN JOAQUIN COUNTY ENVIRONMECEPARNTAL ^tN ; HEALTH ACCEPTED BY: P Lt VEr EMPLOYEE #: ASSIGNED TO: ��'L`4 EMPLOYEE#: �Z'(� DATE: i Lc rD Date Service Completed (If already completed): SERVICE CODE: $,2 L PIE: 3 (Oct L Fee Amount: # OD I Amount Paid a q Payment Date r'ZC(/ I (.) Payment Type �_ Invoice# Check# LI 2 LI L{ Received By: YY fir_ EHD 48-02-025 SR FORM (Golden Rod) REVISED 11/17/2003