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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property ILO CHECK If BILLING ADDRESS FACILITY ID # ( f ^SERVICE REQUEST # BUSINESS NAME V,PHONE#�� a T4�•�G�L{�j` S • I�` 5 OWNS / OPERATOR 151 q (k Y, .. / J,�( HOME OrM ILINGADDRESS CHECK If BILLING ADDRESS FACILITY HAIMIE �(—t 'T 7 I �j� tjl r d v 7 y c411 ) (Jw W SITE ADDRESS S /1 ., I` rN tGt, DATE: rJ ter 7�� Street Number Diredlon lam` Street Name CI ZI Code HOME or MAILING ADDRESS (If Different from Site Address) SERVICE CODE: C (•j 3 i l;G.h 1 fU w yr' Street Number Amount Paid 34 Street Name CITY Lam P (J r sn, �J 3 3 PHONE#1 Exr' APN # VDIQ-Oud LAND USE APPLICATION # (�-Po) ySa -f3oSK - PHONE#2 Ear. BOS DISTRICT LOCATION CODE CONTRACTOR/ SERVICE REQUESTOR REQUESTOR i /I/l i, l.- ILO CHECK If BILLING ADDRESS r Wl. ( f BUSINESS NAME V,PHONE#�� a T4�•�G�L{�j` S • n HOME OrM ILINGADDRESS lvz 'Tian cWK FAX# v 7 y c411 ) (Jw W ACCEPTED BY:LA 14 ( ) CITY k I f� DATE: rJ ter w /1 ZIP STATE c-,14- 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 F aws:- I. % -APPLICANT'S SIGNATURE: DATE: 4 f 2fo /2Z PROPERTY/ BUSINESS OWNER❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT 13 If APPLICANT is not the BILLING PARTY proof of authorization to sign is required TYrte 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 environment site assessment information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at A!1WCNIt is provided to me or my representative. RL:^car TYPE OF SERVICE REQUESTED: �y APR COMMENTS: _ 20 Al �l OpI N COUNT. lvz 'Tian cWK ACCEPTED BY:LA 14 1 Vl (- t)/� EMPLOYEE D V DATE: rJ ter ASSIGNEDTO: ,,r EMPLOYEE DATE: Date Service Completed (if already completed): SERVICE CODE: C P / U Fee Amount: ✓ Amount Paid 34 Payment Date 6' ZCQ�ZZ Payment Type Invoice # ',� �� - Received By: 7 EHD 48-02-025 REVISED 11117/2003 VDIQ-Oud uu� SR FORM (Golden Rod) -