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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID# SERVICE REQUEST# OWNER/OPERATOR 1 A CHECK If BILLING ADDRESS FACILITY NAME tom` SITE ADDRESS Z '3 150 .,)qL,(L 'SNC 9 J. A c- Migo f< Street Number Direction Street Name /�' CRY Zip Code HOME Or MAILING ADDRESS (If Different from Site Address) Street Number Street Name CITY STATE ZIP PHONE#1 EZT. APILAND USE APPLICATION# ( ) 02 050- 0'i F>4 - /Z — ZZC� PHONE#2 Exr. BOS DISTRICT LOCATION CODE ( ) c1 CONTRACTOR/ SERVICE REQUESTOR REQUESTOR � F,/\((/ti 7ro—t CHECK If BILLING AOORESS� BUSINESS NAME DI \! /"�"' PHONE# ./ _ �oG i y Ear. HOME Or MAILING ADDRESS FAX# 7 P !S„� 2I ti o ( ) 334-0?Z- 72 CITY STATE C.A, ZIP I �; -y¢ 1 BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or project specific ENVIRONN ENTAL 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,STATE and FEDERAL laws. APPLICANT'S SIGNATURE: DATE: 3 - 13 - 13 PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER THER AUTHORIZED AGENT❑ IrAPPL1CANT is nor the BILLING PARTr 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 JOAQUIN COUNTY ENVHtoNMENTAL 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: -3 Q /AEC T COMMENTS: �1ZL//3 AIU 1 SAIV'10 /N 2013 nl j(��gil/ 77o HFgGTMO£0vt, ry ACCEPTED BY: f / EMPLOYEE M '2,6-7DATE: / I ASSIGNED TO: EMPLOYEE M 5-C7 (F DATE: 3 (OIL 3 Date Service Completed (if already completed): SERVICE CODE: -L2 1 E: 6 / Fee Amount: Z sjj — Amount Paid � ,l)(� Payment Date / 3 Payment Type Invoice# Check# (�(p3p'7 Re eived By: EHD 48-02-025 SR FORM(Golden Rod) REVISED 11/1712003