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• •. SAN JOAQUI*UNTY ENVIRONMENTAL HEALTIVEPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID# SERVICE REQUEST# G► W,)E 0Isp-,ems►A-)G r,4c-(C I f,► 3 ?Sy 5 51F`15� OWNER I OPERATOR _ ` A lI0I , ) C D UN �. l 0 L L0 AA CHECK If BILLING ADDRESS FACILITY NAME A' ,JM&L)W (:�Z • Po8u c— WaRA.S C0P-rD IQt4`fitwJ Y,444 rStrrE ADDRESS e �- �`I �,V �� Z Q' ! I V Street Number la Street Hama city 21 HOME or MAILING ADDRESS (If Different from Site Address) 1V1,4 Street Number I Stfeet Name CITY STATE ZIP AIM PHONE NI EXT. APN* LAND USE APPLICATION# aoq ) #6?- 3 5 77 PHONE I2 EXT• BOS DISTRICT LOCATION Coce 1 ) CONTRACTOR 1 SERVICE REQUESTOR REQUESTOR J 6 e S eA M CHECK if BILLING ADDRESS BUSINESS NAME PHONE# EXT. BAD Batt RrsEs C. 7- as HOME or MAILING ADDRESS FAX# -2- a M►-G o s ) 36.7 — s- a CITY 4010, a. 0, STATE �'� ZIP C!$'01 q❑ 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 JOAQurN COUNTY Ordinance Codes,Slandards ATE and FEDERAL laws. APPLICANT'S SIGNATURE: DATE: PROP£RTv/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AtrMORIZED AGENT VD. 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 pr U&Wat the above site address, hereby authorize the release of any and all results, geotechnical data and/or environmen i kEament information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available andDMe+aTe�it is provided to me or my representative. fi`� � t� ff II EMIIRONMENTAL TYPE OF SERVICE REQUESTED: 5de /40 AJ/P?rf, W IA IAJ& �y �C HEALTH COMMENTS: 4L1R cg /'4)& Us-fao IPS eya . "vm) 'oe �#*C1� W/A/NG FADA I S'7 Oe 4,L)= V 0 C S6P-C&R `f;l I#c 7"L-S — 3SO CapA UNi t- ACCEPTED BY: Lk t/4E-1 EMPLOYEE M DATE: r It A sSIGNED TO: Q taI EMPLOYEE#: C� [��' DATE: r -(/A Date Service Completed {if already completed): SERVICE CooE: C� Pie Z3� Fee Amount: 4r 4 Amount Paid � � s Payment Date 1 -2 �` b Payment Type Invoice# Check# "a 34 Received By: ti f-{S-- c G— 30.da EHD 48-02-025 3� SR FORM(Golden Rod) REVISED 11/17=03