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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT -91u, 00 a SERVICE REQUEST rc�u+�. �dss�b�� j�aclL �itrlcfs�PPS ACCEPTED BY: Type of Business or Property FACILITY 1D # SERVICE REQUEST # DATE: / ASSIGNED TO: V G� EMPLOYEE ##: DATE: j Date Service Completed (if already completed): OWNER/ OPERATOR pa -bio SERVICE CODE: U CHECK IfBILL1NGADDRESS ® P1 0 Fee Amount: r S 2 Amount Pai FAciuT Y NAME Payment Type Invoice # Check # ; Received By: SITE ADDRESS -i -t 't Cole DYl vt S- o��VE�q5Zt 2S_tlre_atiNumber Direction Name HOME or MAILING ADDRESS (if Different from Site Address) CrY 5tr2et Number Street Name �� STATE zip AM1ly PHONE #1 Exr. ( J APN #r o ®U J' 1 3 OZ -3 LAND USE APPLICATION #f RAN IN ry HEEN �NTy PHONE #2 E cr. ( l BOS DISTRICT LOCATION A Rrn .r... CONTRACTOR / SERVICE REQUESTOR REQUESTflR Robert Sw I �-{ t P"Q 'CiiECK if BILLING ADDRESS® BUSINESS NAME ' vv J �e i. 3 U i1 / -f lt� - z �/ 'T. FiOMc Or fiRAIL1NG ADDRESS � � + 1A w � � FAX #$ p � CITY c 1 /t �� STATE ` �'BP T;� 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 io be performed will be done in accorda C." OAQ111fff � COUNTY Ordinance Codes, Standards, STATE and FEDERAL laws. APPLICANT'S SIGNATURE: DATE: PROPERTY / BusLNESs OWNER ❑ OPERATOR/ MANAGER D OTHER AUTHORIZED AGENT If APPLICANT is not the BILLING PART}' 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 enviro-imentaL/site assessment information to the SAN JOAQUIN COUNTY ENVIRONMENTAL H-EALTH DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. TYPE OF SERVICE REQUESTED: COMMENTS: sl` �Yalvah-avt �Y�� rc�u+�. �dss�b�� j�aclL �itrlcfs�PPS ACCEPTED BY: EMPLOYEE DATE: / ASSIGNED TO: V G� EMPLOYEE ##: DATE: j Date Service Completed (if already completed): SERVICE CODE: U P1 0 Fee Amount: r S 2 Amount Pai // Payment Date Payment Type Invoice # Check # ; Received By: EHD 48-02-025 REVISED 11/17/2003 SR FORM (Golden Rad)