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SANUOAQUIN--1UNTF ENVIRONMENTAL IIEALTPd v-PARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID# SERVICE REQUEST# DPE/V LAND 603� OWNER/OPERATOR QO 141ek:5 -A(06(SE AAlb LANA ^/C, CHECKif BILLING ADDRESSE FAcanY NAME SITE ADDRESS S KoSr.E.e �� • 7,AG}/ 9s2/s 3 '7 /,00 Street Number Direction Street Name C Zip Code HOME Of MAILING ADDRESS (If Different from Site Address) c26, G u� E Ave.` Stm reet Number Sfreet Nae CITY STATE ZIP `"j0 DE 57 p CA �S3S� PHONE#t �T• APN# LAND USE APPLICATN)N# l ) S°z `f ' 393 2GS-090-OS 09 /O PA -03- 3 / 7 PHONE#Y Ext. BOS DISTRICT LOCATION CODE ( ) CONTRACTOR/ SERVICE REQUESTOR REQUESTOR ` , D0n1 `/r E5/Yg CHECK If BILLMG ADDRESS BUSINESS NAME �SIY CO A,S PHONE# El. Iv ) 0_/407 HOME or MAILING ADDRESS FAX# P. O . © l 1108-zs9g CITY u L0 L!< STATE 1,.A 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,ST d FED aws. APPLICANT'S SIGNATURE: DATE: 9-13 —O-4 PROPERTY/BusiNEss OWNER❑ OPERATOR/MANAGER ❑ AUTHORIzED AGENT L7 IfAPPLICANT is not the B/LL7NG PAR7Y proof of autit Hzadon 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 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:^//T2AM 40A`;D/N 50/1- ft(/T4 d/L!T STL(Dl Ef /Q,$� EIVED COMMENTS: SEP 13 2004 SAN JOAOUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT ACCEPTED BY: Lill= � EMPLOYEE#: l (' DATE: �. ASSIGNED TO: EMPLOYEE#: 5 DATE: Date Service Completed (if already completed): SERVICE CODE: Fee Amount: S - Amount Paid Payment Date Payment Type Invoice# Check# - � - °;' Received By: EHD 48-02-025 REVISED 11/17/2003 SR FORM(Golden Rod)