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SAN JOAQUIN COUNTY ENVIRONMCNTAL HEALTH DEPARTMEN I SERVICE REQUEST Type of Business or Property BUSINESS NAMELo L f ` L- �L� 'r FACILITY ID # Fl+ 1) u -7 SERVICE REQUEST # OWNER I OPERATOR Cris* b,�i-I J on CHECK If BILLING ADDRESS FACILITY NAME L J D �� P - t-02- P -e A�r SITE ADDRESS 2 r Street Number r Direetfon w e -f e r Street Name S� L k -+L Y} Cit GPS Z� Zi Code HOME or MAILING ADDRESS (if Different from Site Address) 231 1 Street Number we -b e r Street Name CITY '3-M CI�-y, I ) `J �n_ ZIP STATE C119- �APPLICATION PHONE #9 Ev (2D1) qq(o - 0 q-� PIN # IAND USE PHONE #2 ExT. { ) EMPLOYEE #: BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR %} CHECK If BILLING ADDRESS jo BUSINESS NAMELo L f ` L- �L� 'r PHONE# 04'74 qL1 — "f l[� HOME or MAILING ADDRESS - 2 31 Z F- FAX # CITY S�v L/L-bn STATE CA ZIP qZ OS 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 JOAQi ,N COUNTY Ordinance Codes, Standards �aFAL laws. APPLICANT'S SIGNAT DATE: - % -7 / 2Z ZI PROPER11 IiSINF,SSOWNER OPERATOR AN IGER ❑ OTHER AC711URi/_FA z\CE\T❑ It ifAPPL1CANT is not the BBL LhVG PARTY proof of authorization to sign is required Title e 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. TYPE OF SERVICE REQUESTED: r COMMENTS: VLC:D JUL 0?2 N �11RCNIN CCDNTY aR7A4elVr� ACCEPTED BY: , via EMPLOYEE #: DATE: 7j ASSIGNED TO: no EMPLOYEE #: DATE: I Date Service Completed (If already completed): SERVICE CODE: 3 P I ) Fee Amount: Amount Paid [� a ��' `Check Payment Date 2 l Payment Type Invoice # # Received By: EHD 4&02-025 SR FORM (Golden Rod) REVISED I V1712003