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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property CHECK If BILLING ADDRESS FACILITY ID #SERVICE REQUEST # N�.rbaW� t NutY\tcp Gkub HOME Or MAILING ADDRESS Ave u-+ A �FA00IS 55q 5 R CITY ISI _ `K +t7v\ OWNER / OPERATOR CHECK If BILLING ADDRESS A DATE: ASSIGNED TO: FACILITY NAME New T a N It t r i ',o n EMPLOYEE #: SITEADDRESS -10 , e,UVO, JTe 510 (-IV� Date Service Completed (if already completed): qs2�� Street Nember Dir Street Name Fee Amount: S _ Zip Code HOME Or MAILING ADDRESS (If Different from Site Address) Street �� ' CCS Invoice # Number Street Name CITY �t om \CIU STATE � ZIP J "f PHONE#1 EM. APN # LAND USE APPLICATION # �t (\�\',^ ( WA) -W; 144V PHONE #2 En. ( ) BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR A 1 A /\ v o— �� IC, CHECK If BILLING ADDRESS BUSINESS NAME P— N 1h\ .1 ,L m a LA ' o COMMENTS: PHONE# Exr• -7 15 - -7 4 40 HOME Or MAILING ADDRESS Ave u-+ A ,y' IrOV O 3AZO �if% o Ui, rr r4FNT (A%# ) CITY ISI _ `K +t7v\ STATE CAZip '15aOif 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 associatedwith 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 FEE laws. 1 APPLICANT'S SIGNATURE: L� DATE: PROPERTY/ BUSINESS OWNEIR OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT ❑ If APPLICANT is not the BILLING 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 environmental/site assessment information t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available aW at the same time It is provided to me or my representative. _ AYA&. TYPE OF SERVICE REQUESTED: D,r�!' Gr). rC C T COMMENTS: ,y' IrOV O 3AZO �if% o Ui, rr r4FNT ACCEPTED BY: Vl/k a EMPLOYEE M DATE: ASSIGNED TO: EMPLOYEE #: DATE: (� -aA Date Service Completed (if already completed): SERVICECoDE: �� PIE: () Fee Amount: S _ Amount Paid t Payment Date 'L Payment Type CCS Invoice # Check # Recei ed By: EHD 48-02-025 REVISED 11/17/2003 SR FORM (Golden Rod)