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NANJOAQUIN COUNTYENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID# SERVICE REQUEST# P R/6a 4ru/,-,4 L OWNER I OPERATOR I9/2 G d /Z I TA SOIZR,61,!7"/ CHECK if BILLING ADDRESS E] FACILITY NAME SITE ADDRESS �T 3 Sd u rH STS/�1 C t�G T� D. ,e SC,q G�,�l 7 gS-3 7—D Street Number Direction Street Name CRY Zip Code HOME Or MAILING ADDRESS (If Different from Site Address) Street Number Street Name CITY STATE ZIP PHONE#1 ExT. ApN# LAND USE APPLICATION# 3 f-2.2- x.07-31 -08 21 - 0 ,5- 57ao Su —11 PHONE#2T Bos DISTRICT r Loc ay.,CoDE ,�, CONTRACTOR 1 SERVICE REQUESTOR REQUESTOR CHECK if BILLING ADDRESS BUSINESS NAME PHONE# �• C AE SAvF con�sr c�r��/Cf _Z G� /¢03 HOME or MAILING ADDRESS FAX# -P• C , RDx I ( ) (i&i0 -Z5rg33 CITY u 2 L a GrC STATE CA ZIP S31? BILKING 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 thAap,, 'cn and that work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes,Standard FED APPLICANT'S SIGNATURE: DA'T'E: to • Z 3 , O 7 PROPERTY/BUSINESS OWNER❑ OPERATOR/AfANAGFR ❑ ;01ER AUTHORIZED ACENT 1fAPPLICANTisnottheBILLING PARTY proofofauthtion 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 cnvironmental/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: JV I A L 0 A D 50/4- J u Z 7-A 614 I T lMa WE VV Comro-eNrs: �L � 0.A, ] RECEIVED OCT Z 3 2007 SAN JOAQUIN COUIV7y IiEALTf f p NMEN7?� ACCEPTED BY: { c�t �_ EMPLOYEE M � �` DATE: 0 ASSIGNED TO: 0 AD Lt, D S y EMPLOYEE#: c v�y fs DATE: . 23 f-D7 Date Service Completed (if already completed): SERVICE CODE:S � P I F: 2_60 Z Fee Amount: Lfq o Amount Paid `�45 Payment Date Ie 23 A Payment Type Invoice# Checic# Received By: EHD 48-02-025 SR F.(3RfiVl( o1dr�Rtij' REVISED 11/17/2003 - "