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'U'LECOVEI) SAN.TOA 1. 0UNTY ENVIRONMENTAL HEALT0T) AR*R&*0 Q 2008 SERVICE REQUEST ENVIRONMENT HEALTH Type of Business or Property FACILITY ID# Ft WWWWOMT# (4As sC&-ao t j l 3c)o S 3 n OWNER/OPERATOR c CHECK If BILLING ADDRESS 13 FACILITY NAME SITE ADDRESS . T !� tlk- 's t— q$"-,3-71P L k7 Street Number Direction Street Name C Zip Code HOME Or MAILING ADDRESS (If Different from Site Address) J q S" Bch' [t r„1 k I '- 1 Street NumberStreet Name l� CITY -Rf-U&",40'V`^ STATE C-A ZIP C PHONE#1 EX7, APN# LAND USE APPLICATION# J (qW 140 -410 232 - 1 -70-2 �, PHONE#2 EXT. BOS DISTRICT LOCATION CODE CONTRACTOR/ SERVICE REQUESTOR REQUESTOR CHECK If BILLING ADDRESS BUSINESS NAMEA`_ T� PHO E EXT. HOME Or MAILING ADDRESSFAx# to1�b QU (4(68) o-Q- lQo4-(C, CITY d-,.t t Os e, STATE CA- ZIP n t�'I 1.7— BILLING ACKNOWLEDGEMENT: 1, 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 1 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 FEDERAL laws. APPLICANT'S SIGNATURE: & V. Ltiy DATE: q W QM& p/ PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ,131 U VIA Its AC-Q o'i'C'a:,/ If APPLICANT is not the BILLING PARa 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 is available and at the same time it is provided to me or my representative. c,CS T 4E— / LF l TYPE OF SERVICE REQUESTED: iV- c4t6" ! US's MAV i - COMMENTS: _ r__ l ` ' clv�Ezo-� off- �-e(_�.`Jt C�ea(ti -P lnsQt-e s 14,90V —Row wo-AeK ��N �n SPN Jo O NMRp&- IkA pEPP ACCEPTED BY: ! V r--t e-4 EMPLOYEE#: D DATE: �D Dk ASSIGNED TO: �V N EMPLOYEE#: ��C<Z DATE: i! / o p Date Service Completed (if alr ady completed): SERVICE CODE: 1 ct g PIE: 2,30 Fee Amount: Ctly O� Amount Paid X11,, (Sb—Payment Date Q Payment Type ` Invoice# Check# 05 Received By: Nrzr EHD 48-02-025 SR FORM(Golden Rod) REVISED 11/17/2003