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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property M1 0J FACILITY ID # SERVICE REQUEST # C00��l-�I OWNER / OPERATOR O (�� \� V I CHECK Ff BILLING ADDRESS ❑ FAc m NAME CITY K % (;—j STATE ZIP SITE WRESS, u WWI A I O 11CULy HOME or ING AD E (ff } afferent from Site Address) Street Number pq ^f CITY AIOi %TATE LP 111 'J L/v'D —09— PHONE #1 ExT. Qv�-SV Z USE APPLICAT*" * APN`� �j {� �j 2L.�-2✓V-✓rn SA NJ PHONE#2 E)T• BOS DwmwT C MS CONTRACTOR / SERVICE REQUESTOR CHECK if BILLING ADDRESS ❑ REQUESTOR 01;QK BUSINESS NAME P ' " 1 Z! ExT. HONE or MAiuNG ADDRESSt' 1 r�11 �J FAX# l ) CITY K % (;—j STATE ZIP ANT FD �2 ANT y �FNT 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 TATE and FEDERAL laws. �j �7 APPLICANT'S SIGNATURE: DATE: ✓ ' /� PROPERTY / BusmEss OWNER PERATOR / MANAGER ❑ OTHER AUTHORIZED AGENT ❑ `'gm - I APPLIC not the BILLING PARTY proof o authoritadon to sign is required Title I p ff AUTHORIZATION TOO 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 ENvfRONMENTAL 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:Atly V R N commeT8: VAN_ vp b c � U40 L -'' C. 0!1 5c,tIre cf c> �S 'fir; ��rC%l il� 1�� sr /IC � S s1tf. � �� c�� 11'tJ°'S�fS '�yC.�P }1.P SE' {rL 5 STF'YV1 IS .ri'I f)1F opP0 �'- �' �xp�' i/z sy 2 V ) y fi�Ca� „; )��..:. 1 r:rtvp�'�p�SNP� Sit' 'wl ^JP )1 z� �= r � J„ c> 7 h •- Fr � 3? r ) ACCEPTED BY: -Z EMPLOYEE DATE: 3/8%,2 ASstGNED TO: 04G EMPLOYEE #: DATE: S-/ f/R/ N7 l Date Service Completed (ff already completed): SERVICE CODE: PIE: 930.2 Fee Amount:) S Amount Pa /S2' 6D Payment Date Payment Type Invoice # Check # �� / �� Recelved By: EHD 48-02-025 SR FORM (Golden Rod) REVISED 11/17/2003