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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID # CHECK If BILLING ADDRESS E] SERVICE REQUEST # e,4wo"rJ 3 V — 4,.? — " 17 OWNER/ OPERATOR Svv J"�egl vvi,/ L-,p&reL/G A.,ece ex -- S'rJZ/A G�'/?S (C�/r/ii sK r BILL❑ FACILITY NAME .6�0-971-,_41C C j,1�,vv/7--fey CITY /� �r��' STATE SITE ADDRESS 6 ,�4 d i Il/ yG✓��RD e 1A40 9 5-� 3 Street Number Direction Street Name Fee Amount: city Zip Code HOME or MAILING AnDRESS (If Different from Site Address) �� 0 2 t G (J7✓ t/� Street Number Street Name CITY l�� i vC• STATE C1111 ZIP 7 PHONE #1 EXT, (E07)f6 - �� G APN # o 9� LAND USE APPLICATION # PHONE #2 ExT• BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR C ` �.- CHECK If BILLING ADDRESS E] BUSINESS NAME/�T/ ��U/N CO%'!,✓/ S/ �L✓,v f�//i 1114 ;2v� HOME Or MAILING ADDRESS O � I M � � i � V / (A�� CITY /� �r��' STATE e,$I.. ZIP ,V,5:,2 -eq 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, STATE and FEDERAaws. APPLICANT'S SIGNATURE:DATE: l�.ro PROPERTY / BusiNESs OWNER ❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT Eg 'rE�l ax If APPLICANT is not the BILLING PARTY, proof of authorization to sign is requireld Ti rie ,f0'Z/,D 4-1,411 e' 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: rlf- Q p COMMENTS: %%JIG C /Ntj lac /� A'�7 // /D��/ �A� J�f/'�' ��n /✓E `✓ Flo/c �iliS /�O��idX�N� L✓EGCS (Vel/ .�y /.zc) //✓S,/ft L� �n/� C--**'-��le 1�✓fie ACCEPTED BY:U EMPLOYEE #: DATE: ASSIGNED TO: eff��/ EMPLOYEE #:att / DATE: Date Service Completed (if already completed): SERVICE CODE: P I E: Fee Amount: Amount Paid Payment Date Payment Typel7tJ7 4- Invoice # Check # Received By: EHD 48-02-025 L;V E C L� 111�tt rRJ 1l;olden Rod) REVISED II/17/2003 LLLL��ttJJ 111JJ1 L-�V NOV 15 2007 ENVIRONMENT HEALTH PERMIT/SERVICES