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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or PropertyFACILITY : :1 BUSINESS NAME . ^ , A^ Ij y/ n/ S,bw�1A t uv� 1(/r \ P l 0 / !/ 1 # SERVICE QUEST x J pdO�) Gh CITY5 1 :6 d ki ENVIRONMENTAL OWNER / OPERATOR CHECK if BILLING ADDRESS •,� _ � IOW 2Ml FACILITY NAME S, I^ S- .. wll. )f ^ l„ # Jlit/L IxVhOIi'/in\ 10`] 61 SITE ADDRESS g_lo(� EMPLOYEE#: 1 Cnq e/dU EMPLOYEEM Street Number Olreetion Street Name Cit ZI Cotle HOME Or MAILING ADDRESS (If Different from Site Address) Fee Amount: I U Amount Paid C 2I U S Street Number Street Name CITY S ( 0-461/1 -4 lU t/DL SrRTGe ZIP /]� / �'I (� PHONE#1 N7 (-,7A) Q52 --J033 APN# LAND USE APPLICATION# PHONE#2 ExT (D) 32-Lf -0� z 3 BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR Elm REQUESTOR gV rmc vL r "ktet-�� CHECK if BILLING ADDRESS BUSINESS NAME . ^ , A^ Ij y/ n/ S,bw�1A t uv� 1(/r \ P l 0 / !/ 1 PHONE �/3xr. .yl, VI HOMEyOr MAILR,113ADDR SS FAX# CITY5 �� sT rE zip IE) --b 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, S �TE� and FEDERAL laws. APPLICANT'S SIGNATURE: ( V DATE: PROPERTY / BUSINESS OWNER❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT El If APPLICANT ds not Ute BLLL/Na 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 envirppn��ly7t'el./sCite,'assessment information t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available llrQ�[ 1■"Ttime it Is provided to me or my representative. RECEIVED TYPE OF SERVICE REQUESTED: COMMENTS: SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Ckoolt 6baf r'5hi 2Ml ACCEPTED BY: EMPLOYEE#: DATE: Z ASSIGNEDTO: EMPLOYEEM DATE: 2 r Date Service Completed (if already completed): SERVICE CODE: 1 E: Fee Amount: I U Amount Paid Payment Date / Z-0 2L Payment Type Invoice # Check # Received By: j�or\ EHD 48-02-025 h SR FORM (Golden Rod) REVISED 11/17/2003 S