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NAN JOAQUIN COUNTYENVIRONMENTALHEAL'IllDEPAx1MlaJX1 SERVICE REQUEST Type of Business or Property FACILITY ID# rSEVICE REQUEST# �nsquF OU5- 09-7 OWNER/ OPERATOR 127A Sri-I v u^4 2 Ix!-,4R 069 CHECK If BILLING ADDRESS FACEL[IY NAME I'lA D/,FvA Ce�/V77EA, dF AoPR7-W 5roc4-_ran/ SITE ADDRESS g(Oo7V7rATi�::RRur� gj —x:7AsT FRewrA6 RL) 952/Z Street Number Direction Street Name citv Zip Code HOME Or MAILING ADDRESS (If Different from Site Address) /�Q¢ EA 5T AJA rnMEP, Z/14E: 5u f'TE 7 Street Number Street Name CITY STATE CA ZIP g�Z`O 4 --0/, —J PHONE#11 EXT. APN# LAND USE APPLICATION# (�9} X77 -L-44 0 -300- 3Z = / un�Suodo PHONE#2 ExT. B OS DISTRICT LOCATION CODE CONTRACTOR/ SERVICE REQUESTOR REQUESTOR CHECK if BILLING ADDRESS D su it BUSINESS NAME PHONE# Exr. C 6 oNs c ze HOME or MAILING ADDRESS FAX# 0 . �7 (201 ) G� CITY G STATE &A Z1P C 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 appli on anAthate ork to beperformed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes,StandardsST and Fs. APPLICANT'S SIGNATURE: DATE: 7rZ1`00 PROPERTY/BUSINESS OWNER❑ OPERATOR ANAGER ER AUTHoRIz.ED AGENT IfAI'PLICANT is not the BILLING PARTY,proof of authorization 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: /l/T2 A 7W Z-0A 0 1 Ales- u I•f-ABI4 STu D E-5 R FVr EK✓ COMMENTS: 6 'tel 8 FJ/� fcb ![� p PAY MEIN I IZE-Plw RECEIVED �56ee JUL 2 12008 n SAN NOAQUIN EVIRONMENTA� ACCEPTED BY: EMPLOYEE M HEALTH ATE: ASSIGNED TO: EMPLOYEE#: a DATE: Date Service Completed (if already completed): SERVICE CORE: ?i P i a� Fee Amount: 01 Amount Paid ( L�ato. Payment Date -1 aLa$- Payment Type ,/ Invoice# Check# A17)9 Received By: 74:�,L EHD 48-02-025 5f fORA( olden'F2ad}' REVISED 11/1712003