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212 lAN JOAQUIN C.UUNTY -LNVIRONMENTALriLALTH1)EPARI1VILIN1 SERVICE REQUEST Type of Businpss:or Property FACILITY ID# SERVICE R20',-- 14 OWNER I OPERATOR CHECKif BILLING ADDRESS❑ SCP ft " �u5� LLC. FACILITY NAME Te-1 Ze Ira-- 0l..7-4 P M b e-. .-�y- 19 e '7 SITE ADDRESS �.g3'-3 c } �� l-'�uJ�( wand �. �Va v� �i,� I i Yac�� g 5530 W LOi'V�C.I' d-t Oi�Y� a-IVl �I.OwSe., Street Number. Direction Street Name City ZIv Code HOME or MAILING ADDRESS (if Different from Site Address) i Street Number Street Name r CITY STATE ZIP I PHONE A ExT. APN# LAND USE APPLICATION# 1 1 4�� - O'C' &4/ PHONE#2 ExT• BOS DISTRICT LOCATION CODE ( } S f CONTRACTOR/ SERVICE REQUESTOR I REQUESTOR Vf/ 4- ' I C,k f`e-vt� GAS V`G�-YV1 CHECK if BELLING ADDRESS BUSINESS NAME `/ }` PHONE# �' ' V)9-i ace-- Ktxt, a` Je-5 11 l.vtc- . 201 23q-771Z DOME or MAILING ADDRESS FAX# '31-I I F ( 2a } 234- 72Z7 CITY C } STATE c/A ZIP (?5 2. .J G t4 r` 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 force. 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,S FEDERAL law I APPLICANT'S SIGNATURE: - DATE: 7 /lig o L PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT k-'2r- 6e-, I S !< IfAPPLiCANT is not the BILLING PARTY proof of authorization to sign is required Title 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 environmentallsite assessment information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is F provided to me or my representative. (� i TYPE OF SERVICE REQUESTED: �] �, � j S ac¢ �ofC�c� i v� �i otti 1« oj� P -Iq ! COMMENTS: } 1 � t�J DEC 18 2006 f SAN JOAQUIN COUNTY ENVIRONMENTAL r HEALTH DEPARTMENT ACCEPTED BY: C)L c V EMPLOYEE#: DATE: O ASSIGNED TO: EMPLOYEE#: r'I 38 p DATE: Date Service Completed (if already completed): SERVICE CODE: /s- PIE: Fee Amount7a r ROcfU Amount Paid q O y (K) Payment Date `Z `� t E Payment Typo Invoice# Check# b 2,(- Received By: C� EHD 48-02-025 xSFi:> OFIIUI(Golden Rbii)' REVISED 11/17/2003