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SAN JOAQT*COUNTY ENVIRONMENTAL HEALTI.—EPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID # BUSINESS NAME b (A111ao ooLS ItAS lh/fi• SERVICE REQUEST # PHONE# EXT' 7o 372 LOS -6 Fffi-Mt6 Ssa Q067934 OWNER / OPERATOR Y M I t JD iJWiyA}»L r CHECK If BILLING AODRESSE] FACILITY NAME e EMPLOYEE #: SITE ADDRESS Date Service Completed (if already completed):SERVICE ^_v" rnttAS A,... JQ (�S p� YC ,G+,t•'�L 11 Street Number Direction Street Name city zipCode HOME Or MAILING ADDRESS (If Different from Site Address) Payment Type Invoice # Street Number Check # 8 (s3 Street Name CITY STATE zip PHONE #1p EXT' APN # nn �% LAND USE APPLICATION # () 9"1963 � V�✓'qOI O PHONE #2 EXT. ( ) BOS DISTRICT ®b LOCATION CODE c7 � CONTRACTOR / SERVICE REQUESTOR REQUESTOR CJ 1 r) � n` I �IIC/ � t CHECK If BILLING ADDRESS BUSINESS NAME b (A111ao ooLS ItAS lh/fi• /�,. Q• l.J/VD�� • 'i Z*'L O00' k, JUN 2 2 2098 oPo�� e1V1R0A'MfNT AL a t�o�QPE` PERMITISERV IDES HEALTH PHONE# EXT' 7o 372 LOS -6 HOME or MAILING ADDRESS 7361 GOA-' Wk -Q24- L AJ4— EMPLOYEE #: FAX# (?o7)yu8-379 CITY UkGA Vt LL 2,— STATE zip ,x'68 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 t r performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, Standar TE a D APPLICANT'S SIGNAT DATE: 6-1q — IG PROPERTY/BUSINEssOWNER OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT® COPWAG /L IfAPPLlCANT is not the BILLING PAR TK proof ofauthorization 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 so244s it is available and at the same time it is provided to me or my representative. TYPE OF SERVICE REQUESTED: S �A ?T+,ZA- `` r COMMENTS: /i _ tt t A 7e, , S' \ A I /%V I� i�jl VT I v— ( /�,. Q• l.J/VD�� • 'i Z*'L O00' k, JUN 2 2 2098 oPo�� e1V1R0A'MfNT AL a t�o�QPE` PERMITISERV IDES HEALTH ACCEPTED BY: EMPLOYEE #: DATE: ASSIGNED TO: EMPLOYEE #: DATE: Date Service Completed (if already completed):SERVICE CODE: PI E: Fee Amount: Cris Amount Paid 3Qlk. OL7 Payment Date Payment Type Invoice # Check # 8 (s3 Received By: EHD 48-02-025 SR FORM (Golden Rod) REVISED 11/17/2003