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bAN JOAQUIN I,OUN I y L' NVIKONMEN IAL nEALIH VEPARIMEN'I' SERVICE REQUEST Type of Business or Property FACILITY ID# SERVICE REQUEST# si2c1D 4' 3 �t OWNER/OPERATOR IGv?-'T IZ.PcV'T Z CHECK if BILLING ADDRESS ILS FAGLITY NAME V-�Z e"PE�(->-c4 SITE TRESS Dot`=aD f , �p_�I E(Z P-1> • Li N DE/J q 5234 ZIfP 2'y'-0 Street Number o sire Nm- Cil2i oda HOME or MAILING ADDRESS (If Different from Site Address) moi'f9O � C?C-E)L (0D . Street Number Striot Name CITY 1_001 STATE C.A ZIP PHONE#1 Em APN# o(,s- 2-30-03 LAND USE APPLICATION# (yoq ) 4-f91eO(aS- 24o-Oze -o3 PHONE#2 Esr. SOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR I A.as'j CHECK If BILLING ADDRESS PHONE# E'' BusIvEss NAME L_WE OPclt GEDWJ1'KONYv1ENTYNL_ ypq 30-03W HOME or MAILING ADDRESS �-} W t�lF Sr. FA03-1-- (`L/'1 )3l` ld CITY LSI STATE CA ZIP It 40 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 I have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN CouN'er Ordinance Codes,Standards,STAT nd FEDERAL I s. APPLICANT'S SIGNATURE: �y—/l DATE: SS PROPERTY/BUSINESS OWNERY�1REOPERATOR/MANAGER ElOTHER'AUTHORIZED AGENT❑ 1fAPPLlCA&T is not the B1LL/NG PARTY proof of authorization to sign is required rime 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: XDJiClk-> S�R"F�Lc.E. t S'J$$UR-�i4CE C�NTAtt�lhiPPR oNJ T COMMENTS: / RECEIVED ,P&4�eAlz7 Aeq,44A 30 ; OCT 17 2011 SIN JCAQLN�OUNry / ENYIRONNEM HELLTH DEPARTM� ACCEPTED Br EMPLOYEE#: - DATE: i ASSIGNED TO: 44EMPLOYEE#: DATE:-72 Date Service Completed (If already completed): SERVICECODE: /S PIE: Fee Amount: O`" Amount Paid 42-13) . — Payment Date I O I I I I Payment Type Invoice# Check# 2 Received By: ( 6 EHD 48-02-025 SR FORM(Golden Rod) REVISED 11117/2003