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JAN JOAQUIN I:UUN'IY 1LNVIRUNMEN'IAL nhAL'I'H UlEPAR'I'MEN'1' SERVICE REQUEST Type of Business or Property FACILITY ID# SERVICE REQUEST# OWNER I OPERATOR CHECK if BILLING ADDRESS® (TE(i-RIT tFDFrt'fAN / �PrQyL.L_ QJA(zESY✓�P FACILrrV NAME K p.SSor.J fz�• PRo P�ti�4 r SITE ADDRESS ZG11R(Rs S • S,$Dt-3 P-® • `f12Pc�-y �I�30T Street Number i Street Nama It i d HOME or MAILING ADDRESS (If Different from Site Address) Street Number Street Name CITY p l pq,� STATE Cp, ZIP q S3(n(u PHONE IM ✓ E'T APN If LAND USE APPLICATION,Y (7-01 ) -Z 2SS 2�U -blv P^- ti000(a� PHONE#2 En• SOS DISTRICT LOCATION CODE I I CONTRACTOR/ SERVICE REQUESTOR REQUESTOR f�551 P-f%ce-0 CHECK if BILLING ADDRESS BUSINESS NAMEPHONE# EM' UVE oh1� (fid EP1vIfLp1JMEAITF`L y,q 3(yq- o3}S HOME Or MAILING ADDRESSFAIL# 0-6-4q40-+ VJ• 00,y— ST (21011 1 gt¢i - CITY L,ppI STATE CA ZIP gsyy-p 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,STATE and FEDERAL laws. APPLICANT'S SIGNATURE: III DATE:I PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ OTHER AUTHHHuzr.DAGENT¢a r'ONSt)LTAAr If APPLICANT is not the BILIJNG 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 enviromnentai/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: fL EV I E VU SO/ L S U / r A Tal L.1'T y 577-D y CENE� COMMENTS: #,.1 � ... i „` ►e Ay 2 2011 M^r��`^MI t /) let„VHRi DEPARTMEPI7 I V ACCEPTED BY: / Ow� / - EMPLOYEE#: �L DAA: ASSIGNED T0: `'�jrs 1 O OU W S EMPLOYEE#: DATE: S Date Service Completed (If already completed): SERVICE CODE: P I E: o Fee Amount: .24 po Amount Paid $ 1?-`4 D 0 Payment Date -'S 124( I Payment Type LIZ Invoice# Check# fl ! Received By: EHD 49-02-025 SR FORM(Golden Rod) REVISED 11/17/2003