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SAN JOAQUIN 17OUNTY ENVIRONMENTAL HEALTF T)EPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID# SERVICE REQUEST# � lwC4 OWNER/OPERATOR CHECK if BILLING ADDRESS if F;'v i7�er r/Se FACILITY NAME SfTE ADDRESS I ( �'G (_ ry r� mac./J' f \1 / 51.4 Number Direction Street Name Ci Z7 Code HOME or ILI/N�G ADDRESS (If Different from Site Address) Street Number - Street Name CITY LJ/f STATE Z7P�I�S"6 3 Z�/ PHONE#1 E� . APN# LANDD USE APPLICATION# #Z)44 -CJI-, — `I q ( 1 3 7-/ 706` 183- 32a-,;z l 67 72 9- Off Oo? , 271 PH0NE92 Ez . BOS DISTRICT LOCATION CODE CONTRACTOR/ SERVICE REQUESTOR REQUESTOR� _ S CHECK if BRUNG ADDRESS BUSINESS NAME PHONE# E�' 9-31-13 7 HOME or MAILING ADDRESS Pax# CITY ¢ �p G� STA LP BILLINGVACKNOWLEDGEMENT: 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 Otis form 3 I also certify that I have prepared this application and that the work t be pert will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes,Standards,STATE and FEDERAL laws. APPLICANT'S SIGNA'T'URE: DATE: PROPERTY I BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT I V I L- -/U Is IfAPPUCANT is not the BMUNG PARTY proof of 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 JOAQUw COUNTY EwRoNMENJTAL 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 e l//e s(✓ e �sjJb,$() �2 MA el COMMENTS: APR 2 4 2006 _SAN JOAQUIN COUNTY ENVIRONMENTgL HEALTH DEPA ACCEPTED BY: EMPLOYEE#: DATE: ASSIGNED TO: EMPLOYEE#: 2 DATE: Date Service Completed (if already completed): SERVICE CODE: P I E: Fee Amount: Amount Paid Payment Date Payment Type Invoice# Check# Received By: