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JAN JOAQUIN I..OUN 1 Y ENV] IAL riEAL 1'H OLPARI MEN I SERVICE REQUEST Type of Business or Property FACILITY ID# SERVICE REQUEST# do le&0e' OWNER It OPERATOR L1b-L IAN PENT>EpG(LRiS CHECK if BILLING ADDRESS® FACILIrYNAME PE-NibF-(LGRA 9S PRePtR'Ty SITE ADDRESS 19,73o F- . KET-TLEY�AN LIJ mob I 4 S Zy�O Street Number t Name Zip Code HOME Or MAILING ADDRESS (If Different from Site Address) 19 300 F _ )L.C-rT-L.Ewt/tn.) L/J. Street Number treat a CITY L.ODL STATE CA ZIP gS-;t'40 PHONE#1 Em. APN# LAND USE APPLICATION# (2-o,) ) Sze - 3983 053- I so - I$ PA tz - 00 1S -L- PHONE L-PHONE#Y En. BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REDUESTOR RT5t3y (ZAccc) CHECK if BILLING ADDRESS❑ BUSINESS NAME O AKGEO EN V I ROIJ MEN"T R L PHONE# Ea' toy 3�1- 0-33-5-- HOME Or MAILING ADDRESSIN O Ak $`T • FAT# t 2011 - CITY Lo'DL STATE CA ZIP 1757-40 BILLING ACKNOWLEDGEMENT: 1, the undersigned property or business owner, operator or authorized agent of some, 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 he done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes,Standards, STATE and FEDERAL laws. APPLICANT'S SIGNATURE: Df/,, ,1 DATE: PROPERTY/BUSINESS OWNER❑ OPE TOR/MANAGER ER AUTHORIZED AGENT If APPLICANT is not the BILLING PARTY proof of authorization to sigh 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 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: FEVIEIN $V(LFACE + SV35UKT-ACE C-o JTftMtAJHnC>N (2-C.Pop-f-1- COMMENTS: < L(I PAYMENT /�?��/y RECEIVED 656m� NOV -2 2012 HCOLE4LTMROM1MEMAL ACCEPTED BY: EMPLOYEE#: DATE: 7--� ASSIGNED TO: _ T17 EMPLOYEE III: DATE: it I Date Service Completed (if already completed): SERVICE CODE: PIE: Fee Amount: L4 ZcZ Amount Paid a2- _ Payment Date Payment Type Invoice# Check# V 6-74 Received By: EHD 48-02-025 SR FORM(Golden Rod) REVISED 11117/2003