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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID #7SERVICE REQUEST # COMMENTS: Ill oo I co,2y to SR oogLl Sby OWNER /OPG\A(/oR� '71 CHECK If BILLING ADORESSE] "+ 1� FACILITY NAME 1�0�1; �1V`✓�� ` .. SITE ADDRESS —7—�)-7) �� Cm X.�=—,1"�i� STAT ZIP 2-I �CL(V Street Number Direction Street Name ASSIGNED TO: city Zip Code HOME or MAILING ADDRESS (If Different from Site Address) DATE: Date Service Completed (If already Completed): Street Number I E: Street Name CITY STA E ZIP P1tt�� WW APN # LAND USE APPLICATION # /'PHONE#2 , /T• /' SOS DISTRICT LOCATION CODE Vi7/i� -:r REQUESTOR CHECK if BILLING ADORE 1 L COMMENTS: Ill \ BUSINESS NAME t�.t„ „O 0 (� D .S� (J/ %-(T,n �/X �/f "`tet O L�0 PHONE � Z _ 7 -S5 7�" HOME or MAILING ADDRESS 3 ?c, FAX# .. ��)}' Cm X.�=—,1"�i� STAT ZIP 2-I BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or project specific ENVIRONMENTAi HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as identifled•on this form. I also certify that I have prepared this applicationnL,�d that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, Standards, STAT�[ld FEDERAL laws. 2 APPLICANT'S SIGNATURE: DATE: Ia PROPERTY/ BUSINESS OWNER❑ OPE /TOR/MANAGER❑ OTHER AUTHORIZED AGENT❑ If APPLICANT is not the LL/NG PARTY 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 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: �{MS V V l r �� COMMENTS: Ill `i v I Wi O L�0 3 ?c, y�IxY pF MRty ��)}' ACCEPTED BY: EMPLOYEE #: DATE: �l L ASSIGNED TO: EMPLOYEE#: DATE: Date Service Completed (If already Completed): SERVICE CODE:P I E: ( 1 V Fee Amount (C:5?,i Amount Pa /Sa b?)j Payment Date Z/ Payment Type 0fed l Invoice # Check # Received By:ffT EHD 48-02-025 REVISED 11/17/2003 (�J7 --� 13sS-4�7 PP us2Lfeq(00, SR FORM (Golden Rod)