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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID# SERVICE REQUEST# ('CC U S Z 3c7 OWNER/OPERATOR NF�, 1IIIAeM�p�� CNECKBBILLINGADDRESS FACILITY NAME /3ov W/Tri SITE ADDRESS I IQ Q . JA,C-'( TUIJF 12-U.4,D L-001 1 ,5240 Street Number Direction Street Name city Zip Ce4e HOME or MAILING ADDRESS (If Different from Site Address) Y-s70 G An-&F-l- 7 Street Number Street Name CITY r _ 0 l STATE CA ZIP q (- Z y U PHONE#I V/'"' EXT' APN 0 LAND USE APPLICATION# / J D53-0/{0_ 0213 PA 0¢77-6 PHONE#2 EXT. BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR t-7n N-(L „IA,,Q GL CHECK B BILLING ADDRESS BUSINESS NAME D(��N PHONE# Ext' M v rLt'f 2vl 33q- 660 HOME or MAKING ADDRESS FAx# PL u (?&n ) 33Y-07LT CITY ub 0; STATE C,4 ZIP 61 S-L y ( 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 COUNTY Ordinance Codes,Standards,S A_TEE aan&�w. APPLICANT'S SIGNATURE:Standards, DATE: 10-7,3--o-7 PROPERTY/BUSINESS OWNER 13 OPERRAITTOR I MANAGER ❑ OTHER AUTHORIZED AGENT If APPLICANT 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 environmentaUsite assessment Information t0 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. P TYPE OF SERVICE REQUESTED: C jr _� l COMMENTS: CCT 2 5 2007 OCTE 5 2007 Cl ;7 SAIV E goul/vENVIRONMENT HEALTH 10 ya� � H rNRD P4 TAI PERr�IT!SERVICGS nrr ACCEPTE Y: EMPLOYEE#: DATE: ASSIGNED TO: EMPLOYEE#: DATE: Date Service Completed (H already completed): SERVICE CODE: PIE: Fee Amount: l Amount Paid \ Payment Date luj ZS Payment Type Invoice# Check# $ ` `� Received By: ��- EHD 48-02-025 SR FORM(Golden Rod) REVISED 11/17/2003