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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID# SERVICE REQUEST# 5R Com, c/f- 7 OWNER/OPERATOR j2 pG l`�.�{� �O�I Q CHECK if BILLING ADDRESS FACILITY NAME 17� AF SITE ADDRESS -7, (,-.A/E 1-/1VD,5'1✓ 9523 0 Streel Number Direction Street Name City Zip Code HOME Or MAILING ADDRESS (If Different from Site Address) Zcx, 1 FL-WD Rl0,4 A Street Number Street Name STATE Cd} ZIP 5z3� CITY L/N1JEnl PHONE#1 ExT. API# LAND USE APPLICATION# 601 - 52-52- O//- 350 - c,+ PA - o S - z91 PHONE#2 EXT. BOS DISTRICT LOCATION CODE ( ) CONTRACTOR / SERVICE REQUESTOR REQUESTOR M1 T-V-1 CHECK If BILLING ADDRESS BUSINESS NAME I LL O / r/ PHONE# 33 _66 13 Ex.. HOME Or MAILING ADDRESS /V 7 FAx# (2o-1 ) 334 -0`7z3 CITY STATE �A ZIP 952-I BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or project specific ENVIRONMENTAL HEALTFI 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: DATE: Z— — o PROPERTY/BUSINESS OWNER❑ OPERATOR/MANA OTHER AUTHORIZED AGENT 13- If APPLICANT is not the BILLING PARTY,proof of autltorization to sign is required Title AUTHORIZATION TO RELEASE INFORNIATION: 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 HEALTit DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. TYPE OF SERVICE REQUESTED: SC t L J u 17;�J i L i Ty S /�� — E`,f9,5—: e) COMMENTS: PAYlVir- Q RECEI RUS �Pd�i�`� /� � �� FEB 1 0 2006 v lf�., SAN JOAOUIN GOAN ACCEPTED BY: (f, I lr E/ EMPLOY _TI '{� �R( DATE: — t C V ASSIGNED TO: r S-� �� EMPLOYEE#: { DATE: 06 Date Service Completed (if already completed): SERVICE CODE: Cl 2,7, P I E: Z Cl Fee Amount: c, Z` jZz ti Amount Paid 37,,.VL7 Payment Date wo 6 Payment Type Invoice# Check# Received By: EHD 48-02-025 SR FORM(Golden Rod) REVISED 11117/2003