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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID #SERVII BUSINESS NAME CE )EST #� R (J � U if & HOME Or MAILING ADDRESS _!IJ S' IVO • . SEP 5 U OWNER/OPERATOR(/F •'5 STATE 'Z ZIP 9 S:�t 5 CHECK If BILLING ADDRESS FACILITY NAME G�rDktS•µVt+�1 GINS /v/Gtll�� / (jlr SITEAO� ZStreet LJ�,YyI it S%'yl7 Number Direction Street Name ACCEPTED BY: C` Cit Zip Code HOME or MAILING ADDRESS (If Different from Site Address) / / C J j�/ J I3 {/L• fNj �-G tI4-1 DATE: c) - I. L- I-7 Street Number Street Name CITY / P I E: STATE ZIP^�Q �f PH0NE#1 EXT. (?�, Flo 2,S70S'))(_C)S APN#LAND �voH USE APPLICATION PHONE#Y �� ,J`�. EXT' 12A� II54 ✓ BOB DISTRICT LOCATION CODE a / SERVICE REQUESTOR REQUESTOR LI / CHECK If BILLINGAOGRESS BUSINESS NAME PN N U EXT. HOME Or MAILING ADDRESS _!IJ S' IVO • . SEP FAX # 1071) - -72 2-3 CITY CGB...�-•fC+IG STATE 'Z ZIP 9 S:�t 5 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 FEDERAL laws. APPLICANT'S SIGNATURE: DATE: 7,�( Vv�rt PROPERTY/ BUSINESS OWNER❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT -ALJ {fAPPL/CANT is not the BILLING PARTY proof of authorization to sign is required,/ Title AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, 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. �7 TYPE OF SERVICE REQUESTED: F7�K /2.ot Gil/ EHD 48-02-025 - SR FORM (Golden Rod) REVISED 11/17/2003 117 FEALTH FS 't1 COMMENTS: IVO • . SEP 14 1 JD 5?O ENy/ROIW�}ENT PERMIT/SERA ACCEPTED BY: C` EMPLOYEE #: DATE: CA , I ASSIGNED TO: ir FLA e7p C EMPLOYEE#: DATE: c) - I. L- I-7 Date Service Completed (if already Completed): SERVICE CODE: Z P I E: Fee Amount: L. �tre� Amount Paid 7Sze Payment Date Payment Type Invoice # Ch ck # �s3 D� Received By: EHD 48-02-025 - SR FORM (Golden Rod) REVISED 11/17/2003 117 FEALTH FS