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GAIN aUAkl V[IN %-Uun l i r IN v lKVl\1q Ll\l AL IILAL In 1/L'rt%n A 1Y1G111I SERVICE REQUEST Type of Business or Property FACRITY ID# SERVICE REQUEST E20c� OWNER/ OPERATOR CHECK if BILLING ADDRESS FAciury NAME (LD$E(tTSOrJ SITE ADDRESS ; .w-}fr) 1 S ArJT A lZ� `I 2dlr°l3 1 Street Number n Stnmrt Nam Tf2�cityC T Zi pCode HOME or MAILING ADDRESS (If Different from Site Address) k-+1+0 A AVE. Street Number Street N me CITY SRS )OSI_ STATE CA zip y5-12� PRONE#1 Ex. APN# LAND USE APPLICATION# (.4 4) 13 bs2- lav-of _02 ;,p PHONE 92 SOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR lkaay (LhCGO CHECK ffBauNGAODREss BUSINESS NAME Lt 4C OAK GAO FJIJ V i t2pntrrl Etii7 A LPHONE# - O�`4 S En. HOME or MAILING ADDRESS FAX$ (Zo1) 3(-1-039 CITY LOQ t STATE GA zip CI y Z.{.p ,LING 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 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,STA E a APPLICANT'S SIGNATURE,r DATE: 3 zo k s PROPERTY/BUSINESS OWNER OPERATOR t MANAGER ❑ OTHER AlrrHoRIZED AGENT❑ If APPLICANT is not the BILLING PARTY proofof aulkoriZation to sign iv required Titte AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, 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. TYPE OF SERVICE REQUESTED: F-WIEw SUR-FACE r 50&SV2f?kCF COO. T-AVKlN'brnC0') 9CP02T CDMMEWS: PAYMENT ,A a4/ jw ��6°,,.:�� RECEIVED ��') ks ? yk"' 2 5 2013 slttlll CbN� /�'z �e " SAN JOAQUIN COUNTY ENVIROMEN;AL ACCEPTED BY: EMPLOYEE#: r i r6 r%- _L DATE: As TO: Ivkiy�C k EMPLOYEE#: l.,S to�kJ DATE: y Date Service Completed (if already completed): SERVICE CODE: f j P t E: Z6o Fee Amount: '�j t2.0(? Amount Paid/1a - Payment Date sJ Payment Type Invoice# Check# y-t lZ Received By: EHD 4"2-025 SR FORM(Golden Rod) REVISED 11/172003