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SAN JOAQup,1:OUNTY ENVIRONMENTAL HEALTP DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> E L��Q� <br /> OWNER/OPERATOR <br /> N QtL_ Ro75�2TsolJ CHECK It BILLING ADDRESS <br /> FACILITY NAME (ZO5E(2-TS01J FXOPtRTy <br /> SITE ADDRESS Zcl L4(P S• L.�ti M teatJ Pt:D . <br /> Street Number imc n Cit Zi God <br /> HOME or MAILING ADDRESS (If Different from Site Address) Z�'j3} S , $f4 PJ-T P (Z� <br /> Street Number Street Name <br /> CITY T.RR Cy STATE CA ZIP 95-604 <br /> PHONE#1 Ex . APN# LAND USE APPLICATION# <br /> (2-o9) 91&+ - 13'12- 253-330 -10 >? p - O-1Z <br /> U to <br /> PHONE#2T• BOS DISTRICT LOCATION CODE <br /> l ) GL•Ct <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQUESTOR NT5gy Q�C-4%%CCHECK If BILLING ADDRESS® <br /> BUSINESS NAME l PHONE# - Em <br /> Lt VC 0?dL Cs£0ECJVhRONME/JT'P�l.- _ 7.o1 31409- o3--S- <br /> HOME or MAILING ADDRESS <br /> FAx <br /> FFo} W. 0hp-1 sT. (y01)3tp1- 03-+5' <br /> CITY L01>( STATE Ctt< ZIP G152'�•O <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or <br /> activity will be billed to me or my business as identified on this form. <br /> 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 <br /> COUNTY Ordinance Codes,Standards,STATE and FEDERAL laws. / <br /> APPLICANT'S SIGNATURE: � 4 JI <br /> DATE: <br /> D <br /> PROPERTY/BUSINESS OWNER 13 OPERATOR/MANAGER ❑ OTHERADTHORamAGENT® e0KI;-Vl <br /> If APPL/CANT is not the B/LLtNG PA2T1'proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable,I, the owner or operator of the property located at the <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: REViEvJ S�7R FI4CE } $11�1J'PrtCE CANTAN'l(tJPfTl o/J fZEPoIZT <br /> COMMENTS: �(ty I�, PAYMENT <br /> RECEIVED <br /> y'Zl�ta <br /> APR 2 7 2010 <br /> SAN <br /> ENVJOAQUIN TM <br /> ENVIRONMENTAL <br /> ACCEPTED BY: p L( v L EMPLOYEE#: O'3 DATE: LF 27 (0 <br /> ASSIGNED TO: !4S f O V LA-t-US EMPLOYEE#: 4-045 DATE: r f Z-7 /C7 <br /> Date Service Completed (if already completed): SERVICE CODE: 315- P f E: oz 03 <br /> Fee Amount: ;?-3 O. [7D Amount Paid .�'U Payment Date I <br /> Payment Type - Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/1712003 <br />