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SAN JOAQUIN COUNTYENVIRONMENTALHEALTHllEPAR`1'MENT SERVICE REQUEST Type of Business -'r Property FACILITY ID# SERVIC ST# OWNS TOR 5D T �VEGoPM>ENT /�R , A -/�9 rc*14e4 S0L1v,4 CHECK If BILLING A F ,CE 14 E D Si 1<fG SIT DDRESS a2-f57-00 S nmY In,4 CAiZT940Z 72.4 C y O'S-3 76 Street Number Direction Street Name c-Ity Zip Code HOME or MAILING ADDRESS (If Different from Site Address) 10!5- EA7 -57— -5-7-,Ce-Er Street Number Street Name CITY STATE CLQ ZIP 9�3 PHONE#1 EXT• A_ PN# LAND USE APPLICATION# (Aaf) 1-25-0 4-0 -a/ P - oma- 7-7sA PHONE#z ExT. BOS DISTRICT LOCATION CODE CONTRACTOR 1 SERVICE REQUESTOR REQUESTOR CHECK If BILLING ADDRESS BUSINESS NAME PHONE# EXT. C' �SNg C'a�rSuGT Nc ) 4G0.-Z40 HOME or MAILING ADDRESS FAX# X ( ) loly -Z� CITY G STATECA ZIP �38 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 and that the work to be performed will be done in accordance with all SAN JOAQUIN k COUNTY Ordinance Codes,Standards, ST nd FEDE laws. APPLICANT'S SIGNATURE: DATE: PROPERTY/BUSINESS OWNER❑ OPERATOR/ ANAGER ❑ THER AUTHORIZED AGENT IfAPPLICANT is not theBILLINGPRRTY,proof of a orization 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 provided to me or my representative. TYPE OF SERVICE REQUESTED: �(_�,rg D f!O 4 SGf </T n " UKP Vt E COMMENTS: DF t, JMktlV'�"G'�t,� OF I w�tir� �14'�.M�"r S. r1rob RECEIVED & o{o !�""�""_ ' `�P�-fb,•tr O `t -� � EB 10 2006rtpll� .0 rA qv.' erf 0l -E iAr� AN JOAQUIN COUNT'w 5;4S - ENVIRONMENTAL ACCEPTED BY: EMPLOYEE#: yjoao DATE: 0 ASSIGNED TO: EMPLOYEE M DATE: 0 Date ice Completed (if already completed): SERVICE CODE: �2� P!E: Fee A 50. Amount Paid I 1 O rJ p Payment Date �D �b PaymentT Invoice# Check# 'J Received EHD 48-02-025 SR RM'(Gol[len Ffod) REVISED ii117/2003