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SAN JOAQ`rd COUNTY ENVIRONMENTAL HEALrt. DEPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID # SERVICE REQUEST # �AeOl�l'/Yl ISE Kcsibtx4+(�1 C, (- Z LA OPERATOR ( �1 CHECK If BILLING ADDRESS yn A fro[ �^ LLC (j-] fry h.C.N' ((U.- FACRRY NAME (f 1' Ally) 9 $ jU 7 e ASSIGNED TO: IE N fi Qr_ C SITE ADDRESS Uli+ � — -� ' 11 Om /� ` 53 Rp Street Number Olraedon Street Nama C 21 Code HOME or MAILING ADDRESS (if Different from Site Address) 9:711 y /� 1 ^ y� I I i �c7Q._ CI CXD Amount Paid n1 q S, �,� Street Number In# fiet Name Payment Payment TypeCe"�I v CITY- .. DIL STATE ZIP^j �^yc_ / ( �J�' PHONEA ( 141-74-X81 ExT. APN # LAND USE APPLICATION # 248IIIQty PHONE#2 EXT. SOS DISTRICT LOCA7IQNOOE CONTRACTOR / SERVICE REQUESTOR REQUESTOR kia-�h er CHECK If BILLING ADDRESS® S_tLrnn.�t-s BUSINESS NAMEGPHONE# EX7. ' F� )�G HOME or MAILING ADDRESS F # ...��^^^�� CITY _. I �' 1 �SaATE ZIP �Tc/75,i BILLING ACKNOWLEDGEMLNT: 1, the undersigned property or business owner, operator or authorized agent of same acknowledge that all site and/or project specific ENVIRONMENTAL HEAuni DF.:PAm mwr 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 t have prepared this appl' tion and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, Standards, T And FEDERAL laws. �Q APPLICANT'S SIGNATURE: I-�-) DATE: �ayy-IAA``ty�� PROPERTY/BUSINESS OWNER OPENA'1'OI/MANAGER ❑ OTHER AUTHORIZED AGENTS 1C3'¢ ' If APPLICANT is not the BILLING PlitirY 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 to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as Soon as it i5 available and at the Same time it is provided to me or my representative. TYPE OF SERVICE REQUESTED:e �N o C p r ,E hC.O COMMENTS: RUSH ✓ t G AUG 2 S 2008 AFS` ° 2008 SAENVIRONI HEALTH DEFIE' VI7 l:.?gC'rJl �f1LjiL[!� ACCEPTED BY: �r-..� t /� it 4_ F`Ci'l rY)i ��/J=i'4 E1`bYEE#:0,3 y. DATE: e -s Dg1 ASSIGNED TO: IE N fi EMPLOYEE #: S`� y DATE: 2 4 G, Date Service Completed (if alrea y completed): SERVICECODE: --3,/PIE: ,3(J Fee Amount: Amount Paid n1 q S, �,� Payment bate 8 - Payment Payment TypeCe"�I v Invoice # Check # & 3 13 Received By: �Z EMD 45-02.025 SR FORM (Golden Rod) REVISED 11117/2003