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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID# SERVICE REQUEST# A OU23Ny10 500 gsol I� OWNER I OPERATORCHECK If BILLING ADDRESS FACILITY NAME JOU�17viJC+sK C�MPf{N S' I�c�olJ SITE ADDRESS j g q W ,,t /ICH 1 C /, S' l or- CD'iJ '%—r4l Street Number Dlreetlon I_' f Street Nalm�e `7 CI 2i Code HOME Or MAILING ADDRESS (If Different from Site Address) `1 ��;L p 503 Street Number NIS i Street Name CITY ,{`x STATE CA zip qG PHONE#t 1 ExT APN# LAND USE APPLICATION# ofCJ (..Y09 PHONE#2 Ex. BOS DISTRICT LOCATION CODE ( ) CONTRACTOR / SERVICE REQUESTOR REQUESTOR ,+ g CHECK if BILLING ADDRESS0 BUSINESS NAMEPHONE# Exr. HOME or MAILING ADDRESS FAX# 4503 Nim 1 Df-- ( ) CITY S YAC K-/b r) STATE C'�44 zip 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,SATE and FEDERAL laws. ARAftMAM118SIGNATURE: `/�llo� a�lh hllu� DATE: —� PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER OTHER AUTHORIZED AGEMf❑ If APPLICANT is not the BILLING PARTY proof of authorization t0 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: COMMENTS: OWL6O of UL]( Cl ACAUA L1>tiVlN-A�"F�lh'VOct o �� 19 ZDV H oEa4 MAL lY ACCEPTED BY: EMPLOYEE#: DATE: I V—111- 22 ASSIGNED TO: EMPLOYEE#: DATE: Date Service Completed (if already completed): SERVICE CODE: PIE: IYV2 Fee Amount: I S Amount Paid I S(ar bO Payment Date Payment Type Invoice# Check# ReceivdBy: EHD 48-02-025 SR FORM(Golden Rod) REVISED 11/17/2003