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(�-1 ,r.,JVN 1� 1'41, 11 Sul 6 rA 70� I LA SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type ness or Property BUSINESS NAME FACILITY ID # HOME Or MAILING ADDRESS SERVICE REQUEST # r SAN JOAQUIN COUNTY ENVIRONMENTAL 3P,002(01 35 OWNER/ OPERATOR "•, ' CHECK If BILLING ADDRESS FACILITY NAMEc Qf U M r DATE: \Z —6i - 2 SITE ADDRESS'G-+I Street N r Direction SERVICE CODE: 1(0,02_ M"A I O'l t Street Name C�1� city Code HOME or MAID D, ESS (If Different from Site A dress) Payment Type G L Invoice # Check # (/ Q "N Street Number Street Name CITY STATE ZIP CA Y W— PHONE#t EXT• APN # LAND USE APPLICATION # ( D) - f-4-1 PHONE #2 EXT. ( ) eOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR CHECK if BILLING ADDRESS BUSINESS NAME PHONE # EXT' HOME Or MAILING ADDRESS FAX # CITY STATE 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, STATE and FEDERAL ^ 1. w C APPLICANT'S SIGNATURE: �/� dry V V1 DATE: I �Z' �0 rlit� PROPERTY / BUSINESS OWNER 13 OPERATOR/ MAD TIGER ❑ OTHER AUTHomZED AGENT ❑ If APPLICANT is not the B/LL/NG 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 enviromnental/site assessment information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the Sante time it is provided to me or my representative. TYPE OF SERVICE REQUESTED: C4 PAYMENT COMMENTS: RLOCrCD DEC 0 9 1022 SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT ACCEPTED BY: �,/./� b Y 1 EMPLOYEE #: DATE: \\L ASSIGNED TO: G t I EMPLOYEE #: DATE: \Z —6i - 2 Date Service Completed (if already completed): SERVICE CODE: 1(0,02_ PIE: Fee Amount (% _ Amount Paid Payment Date Payment Type G L Invoice # Check # Received By: EHD 48-02-025 REVISED 11/17/2003 cv,, � I S140 779 5 S Pro "I l/ SR FORM (Golden Rod)