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CY 1NJ"AVVLIN LVUIN1IL' IVV1I-"1NiV1rIN1AI, 11GAL1" 11H,rEllai1v1E1\1 SERVICE REQUEST v Type of Business or Property FACILITY ID# SERVICE REQUEST# G'OmmElZG'/A-L 5 Coo 5 z 9 35 OWNER/OPERATOR Fc,e,eEGz- x.45 6a GLUE RNiN� CHECK If BILLING ADDRESS FACILITY NAME 431-6&F RAIIA10 SITEADDRESS /2 &67 /2633 SOU7W /t'I.4A/7-y61 LAT/-/2pP '?S-330 Street Number Direction Street Name city Zip Code HOME or MAILING ADDRESS (If Different from Site Address) A� COROIVAD O Street Number Street Name CITY STATE ZIP STo�K oN PHONE#1EXT. APN# LAND USE APPLICATION# (�0 ) 9�3 -boa / 1.7 -a 30 -o7 P,4 - 07- 3/5 5A PHONE#2 Exr. BOS DISTRICT LOCATION CODE :20 f) G3/ - 2025 :3 4 9 CONTRACTOR/ SERVICE REQUESTOR REQUESTOR ON CHECK If BILLING ADDRESS CNESn/� BUSINESS NAME PHONE# E'' yESVE Con/Su�ri.V� 403 HOME or MAILING ADDRESS FAx# P. o . BoX 37-r4 ( ) GGS-zs9g CITY u 2 L O -k STATE ZIP 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 appy on and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes,Standards, S and 5— S zAPPLICANT'S SIGNATURE: / j� DATE: /Z - I3 OPROPERTY/BUSINESS OWNER❑ OPERATOR/ IANAGER O ER AUTHORIZED AGENT If APPLICANT is not the BILLING PAR proof of auth ization 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: N/TK ATE GDAD/n/ SD/L SU 7-AS(I-/rY 17-aD/s5 E COMMENTS: t �'/13/ted 121;1/vi /vL ( y� .r,,.,) ""�� s DFC 13 ?Op7 12/ZG/v/ Gj�jlrJL( 3orn,n l,l� JOA/VV/R U'NC U I/Y I/ s "it44( '?4m ) -11T/ HfALTN p pMRtY 1y ACCEPTED BY: (>]� .t V E t 1J� EMPLOYEE#: O,3 Z/ DATE: /z//3 0 7 ASSIGNED TO: L� E t ICC EMPLOYEE#: -7 ?�-7 DATE: I >—//3/07 Date Service Completed (if already completed): SERVICECODE: rj 25 P i E: -Z 6 O2 Fee Amount: -0 Lfq D. 00 Amount Paid Payment Date Payment Type Invoice# Check# Received By: EHD 48-02-025 SR FORM'(Golden Rod) REVISED 11/17/2003