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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property CHECK If BILLING ADDRESS FACILITY ID # P Fc - 1 ' OPAP�Y�� SERVICE REQUEST # fZE.TA1 R50LigE- DG't)C CITY 1 . ! C p CCL AVIA ► (C SINGa qL G7 SAN NV PONMENT�' OWNER I OPERATOR ACCEPTED BY: CHECK If BILLING ADDRESS ❑ - E( - EV A .tC. DATE: ASSIGNED TO: V Kk 1 P A A U FACILITY NAME Date Service Completed (if already completed): SITE S _ I �A Ar l ti( S r R E r-- T W1 A a l t E C A 9 5 3 3 6 pADDRES C( i Street Number Direction Street Name city Zip Code HOME or MAILING ADDRESS (if Different from Site Address) PQ 0Y, v T Street Number Street Name CITY p N L L IN,s STATE ZIP � szi r -o�t� PHONE #1 EXT. APN # 21�33�>3y LAND USE APPLICATION # (-Z S-3) -+ 6 - }I-4-0 PHONE #P EXT. ( )113 BOS DISTRICTLOCATION 11 CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR :M ( C,A Ar E L � / A L � rr R W ` CHECK If BILLING ADDRESS BUSINESS NAME �� _ JAL'r0�( 1��C.I�EER(��t, P Fc - 1 ' OPAP�Y�� PHONE # Exr- 916 3}3- /(5 - HOME or MAILING ADDRESS 17.A. T3�7C /OZ� FAX # (9(6)3}3— CITY 1 . ! C p CCL AVIA ► (C STATE (7 A ZIP c� _5-6 q 1 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 anp that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, Standards, STATE and F DERAL laws. APPLICANT'S SIGNATURE:q DATE: 9/2--t 0� PROPERTY / BUSINESS OWNER❑ OPERATOR /MANAGER ❑ OTHER AUTHORIZED AGENT M C O wr R A--f—-OrL- If APPLICANT is not the BILLING PAR 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 -.:.t..A �.. mo r.r m P1lrPCPntatl\!P YaVvau+u w uav v+ ...� ...Y--.------- • -- TYPE OF SERVICE REQUESTED: ( Q (�( != V l FitAJ P Fc - 1 ' OPAP�Y�� COMMENTS: V 2 � 2006 SEP n SAN NV PONMENT�' pEppRTMENT ACCEPTED BY: EMPLOYEE #: C DATE: z . DATE: ASSIGNED TO: V Kk 1 P A A U EMPLOYEE #: Date Service Completed (if already completed): SERVICE CODE: ( �/ P / E: 2 30 5 Fee Amount: Amount Paid D s U Payment Date Gt Z S Payment Type `/ Invoice # Check # Received By: EHD 48-02-025 SR FORM (Golden Rod) REVISED 11/17/2003