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SAN JOAQUI"� OUNTY ENVIRONMENTAL HEALT"DEPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID# SER,/VICE REQUEST# ��S EDF�/TrA G✓in/E2 I//n/E AR 6em42—&C 2— OWNER/ OPERATOR / CHECK If BILLING ADDRESS FACILITY NAME SITE A[}DRESS ink L//SNE �0,4 P 71Z,AC ¢ 2 Street Number Direction Street Name city Zip Code HOME or MAILING ADDRESS (If Different from Site Address) Street Number Street Name CITY STATE ZIP PHONE#1 `` EXT. APN# LAND USE APPLICATION# ( ) ��S - 3a13 „25 3 -aic- ,;t s P -o4 -.S97 FPHONE#2 E T• BOS DISTRICT LOCATION CODE ) CONTRACTOR/ SERVICE REQUESTOR REQUESTOR CHECK If BILLING ADDRESS BUSINESS NAME CW�(�� 'V �/�1 / LT /v C PHONE# 4 (GO- 14-03 Ecr' HOME or MAILING ADDRESS l� FAX# 6 ox 3 ( ) 02 -zs9� CITY1 �L OL 1< STATE `^� ZIP L?-5 BILLING ACKNONVLEDGEMENT: 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 ap ocation and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes,Standards TE and F RAL laws. APPLICANT'S SIGNATURE: DATE: f,, — -C PROPERTY/BUSINESS OWNER❑ OPERATOR/NIANAGER ❑ OTHER AUTHORIZED AGENT If APPLICANT is not the BILLING PARTY,proof of atuthoriZation 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: N/TRATE Se L Sa/rAr3/L /;Z 5*7-"D I'F-5 —,1^ ,5:'D1 TEP lFeVI f W co MMENTS',A1VE� ��N 6 205 rt / SAN 30A,�y'�NiAEOO AN ACCEP[��LtY: L I t✓' t LQ ,[� EMPLOYEE#: �, %�1 DATE: 6/& S ASSIGNED TO: /. �: EMPLOYEE#: 4 / DATE: �" �, (Cj Date Service Completed (if already completed): SERVICE CODE: S /-?24S-- P I E: Fee Amount: L)j( I �`- /e`�l- Amount Paid -5 � ( 7 SL- Payment Date b Payment Type Invoice# Check# � Received By: EHD 48-02-025 SR FORM(Golden Rod) REVISED 11/17/2003