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3A1N JVA11U11N L..VUPiIY ENu rAnilriciNl SERVICE REQUEST Type of Business or Property FACILITY ID# SERVICE REQUEST# / T Ef/D£NTI,�IL OWNER/OPERATOR CHECK If BILLING ADDRESS C/RCGE FACILn-Y NAME Cl 2LcF T, m. ESTATES SITE ADDRESS 2&42-t tpNTf/ IW,4,vTECA e-9f Gt- A14AITECA 9s3 37 Street Number Direction Street Name C Zi Code HOME Or MAILING ADDRESS (If Different from Site Address) T n'/O Ale "P r // 7o lO Street Number Street Name CITY STATE ZIP I PO A/ CA S 6 PHONE#1 Ev. APN# LAND USE APPLICATION# ( ) Sg9 -S/ro7 a4,7-/so 27-0-0zo7/?1 PHONE#2 Err. BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR DoAi C ESTE y CHECK If BILLING ADDRESS BUSINESS NAME PHONE# �' CNESNE C NIULT n/ 66 S• � o� HOME or MAILING ADDRESS FAX# P_ O • sex 3 71 1 ( ) CITY STATE CA' ZIP S3 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 preparedthis ap 1'cation and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes,Standards, TE and Fp65kAl.laws. APPLICANT'S SIGNATURE: DATE: PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGEROTHER AUTHORIZED AGENT 19/ If APPLICANT is not the BILLING PARTY proof o❑authorization 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 CouNiY 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: fURFACE A-Al6 -CNBSGIRFACIF OA/TArnIN<IT/Ong R6RRE✓tE k/ COMMENTS: 7 I D y/�j� ��'��T-D � + '-/06 £CCC//060 A ul e.r..1 S 2006 AN J H NVIRgONIAI`"OVAgY �LTyD 'HENT ACCEPTED BY: EMPLOYEE#: - 3 DATE: T ASSIGNED TO: EMPLOYEE#: O DATE: Date Service Completed (if already completed): SERVICE CODE: '�( 'S P 1 E: Fee Amount: t Amount Paid !� �� j Payment Date 3 l (S6 Payment Type Invoice# Check# 2 S -55 Received By: I v o- EHD 48-02-025 SR FORM(Golden Rod) REVISED 11/17/2003