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JAN JOAQUIN L LUN I ENVIRONMENTAL HEAL GI'H DEPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID# SERVICE REQUEST# Oo bo� OWNER/OPERATOR LILLIAN PEnIDEt2s1eftS9 CHECK It BILLINGADORE33 FAclUTY NAME PENDCKG12A9S PP-O P E(LT y SITE ADDRESS 9130 �• KE7TLCr"AN W - L_OZ71 gS2'/0 Street Number DI on L C HOME or MAILING ADDRESS (If Different from Site Address) 11300 E• I<eT-rL..t:wl its L!U . 3t Number e CITY C_ODI STATE GA ZIP 9S2-40 PHONE#1 Exr APN# LAND USE APPLICATION# 1201 ) '1'Z-+ - 3983 OS-3 - ISD- 1 $ Qft,z - ootS-z PHONE#2 En. BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR Aagy 9-141vCCO CHECK If BILLING ADDRESS BUSINESSNAME L-t\)E OhK- GEOCNVIRoNWt£NTf\L_ PHONE# En zo91 3 fog- o3 HOME or MAILING ADDRESS FAX# q,)-4 L.J. oIYK- sT. ( Zen) 3to l - 03�� CITY LDUI STATE CA ZIP qty 40 BILLING ACKNOWLEDGEMENT: 1, 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:7�, yQ��1,7- DATE: PROPERTY/BUSINESS OWNER El / PERATOR/MANAGER ❑ OTtWR AUTHORIZED AG ENT /fAPPLICANT is not the BILLING PARTY proof of authorization to sign AS 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 environmental/site assessment infomlation 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: ILF-V l EW SDI L- SU ITATi1 L I Ty 5'rV�y COMMENTS: s/- -8-12 RECEIyNT Al.f/E� sco�caj,^^^^' yp NOV -2 2012 -7 HE4k-,},Rp PMEn4L ACCEPTED BY: 'ty/( EMPLOYEE#: DATE: /.-- ASSIGNED TO: / 6crff o EMPLOYEE#: DATE: Date Service Completed (if already completed): SERVICE CODE: 5-y v P I E: Fee Amount: Amount Paid �� . Payment Date 1 ( yl I Z Payment Type Invoice# Check# s-Iy Received By: EHD 48-02-025 SR FORM(Golden Rod) REVISED 11/1712003 4E