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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property '' 1A� \`1trr1�. CHECK if BILLING ADDRESS FACILITY ID # A,CCEorcr)gv• n /^� Rew �tk SERVICE REQUEST # u V EMPLOYEE#: O(.��-7 2'fDg Date Service Cortrlete . ('f !ready completed): S Ad OWNER/ OPERATOR �d Farhh (owe CHECK if BILLING ADDRESS FACILITY NAME. t, STATE zip g53't fP� a Check # 0 Received By: SITE ADDRESS 1 f. N a,^ r 1u dG 6N S'2v 7 �al b425 Street Number Irectlon Stre e DR Dnde HOME or MAILING ADDRESS (If Different from Site Address) Stre¢t Number Street Name CITY STATE ZIP PHONE #1 Em. 1 ) I APN # Oq-7' j(p3—CSS LAND USE APPLICATION # PHONE#2 Em. I ) BOS Dlsl$JCT L 11 LOCATION CODE el CONTRACTOR / SERVICE REOUESTOR REQUESTOR �^A '' 1A� \`1trr1�. CHECK if BILLING ADDRESS BUSINESS NAMI -'(poo A,CCEorcr)gv• n /^� Rew �tk PH NEI Em' �0 537-b5oo u V EMPLOYEE#: O(.��-7 DATE: (sljJ Date Service Cortrlete . ('f !ready completed): HOME or MAILING ADD SS Ad FAX# l ) �d Farhh (owe -a�� —� CITY t, STATE zip g53't fP� Invoice # BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowled e 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 l have prepared this application and that the work to be performed will be done in accordance with all SAN JOR.QUI'I COU'N ['; Ordinance Codes, Standards, STATE and FEDERAL laws. Q / APPLICANT'S SIGNATURE: ,I ,( DATE: " (D—d 17 PRUPI'11(f Yi dGJINESS OWNER❑ OPERATOR I MANAGER El OTn l AUTriORIZED AG EIC 1' y.IPI'LiGANT is not the BILLING PARTY, Proof Of allthOTilatiOn to sign ii Tegnired Title 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 ENVIRONMENTA]. HEALTH DEPARTMENT as soon as it is available and at the same time it is provided In ute or my representative. TYPE OF SERVICE REQUESTED: APR SAN JOAQUIN COLIN ly ENVIRONMEN�� T EHD 48-02-025 SR FORM (Golden Rod) REVISED 11/17/2003 A,CCEorcr)gv• n /^� Fnnoi nycc #: HATE: �H/E'AL`T�H/DEPAR ASSIGNEE) TO: /t"T �/T_, ESQ EMPLOYEE#: O(.��-7 DATE: (sljJ Date Service Cortrlete . ('f !ready completed): SERVICE CCDE: S ZZ PIE: 3�OU•Z 1 Fee Am �� Amount Paid -a�� —� Payment Date L� �/C Payment Type Invoice # Check # 0 Received By: EHD 48-02-025 SR FORM (Golden Rod) REVISED 11/17/2003