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IAN JOAQUIN FLOUN1'Y ENVIHO.INML'N'I'AL nEAL'I'H DEPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID# SERVICE REQUEST# 6A a 61(02 Z e4 OWNER IOPERATOR € Tor^ •+ fJ0 ErN I A Ott VE I R-A CHECK if BILLING ADDRESS to FACILITY NAME OLIVE 1 RLA PIROPEP T\1 SITE ADDRESS t g 3�5 1,_,O b 01 9;?—,+Z ' 0 3-4 y Strset Number D r tlOn Street Nam icode HOME or MAILING ADDRESS (if Different from Site Address) D I 1 t R Street Number Street Name CITY -r STATE CA zip A TYMP PHONE#1 1� T EXT. API# LAND USE APPLICATION# I ov 9z0 - -- -s3 vs PHONE#2 EXT. BOS DISTRICT LOCATION CODE (7AM) W-11-0 - 2-532— CONTRACTOR/ SERVICE REQUESTOR REQUESTOR A55--4 AACLO CHECK ifBILLING ADDRESS❑ r BUSINESS NAME U V E OAK PHONE# EXT tort '510 o3"I-s HOME or MAILING ADDRESS FAX# �Fo} w • Urkr� S`T. ( ") 3(09 -0.61-4 CITY STATE L A zip 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,STATE and FED'RAL laws. APPLICANT'S SIGNATURE: J4,:1 PROPERn'f BUsINEss OWNER❑ OPERATOR]/MANAGER ❑ OTHER AUTHORIZED AGENT LCF t6-ASJ11+RA11-1 If APPLiCANT is not the BILmyGPARTY.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. t TYPE OF SERVICE REQUESTED: X"ICW SVXr0NCC f SV1�S�3R-t'AC� CoNTA1N#AIRT10pJ J2.f-P0W'J COMMENTS: �! '5I1.e f I i PAYMENT �g7AVr14, RECEIVED AY r c64 MAR 3 4 2011 SAN JOAOUIN COUNTY ENVIFQM1IMENTAL ACCEPTED BY: EMPLOYEE#: ASSIGNED TO: C S C-0 V-Z> EMPLOYEE#: sQ t DATE: d / Date Service Completed (if already completed): SERVICE CODE: `J!' P i E: (oQ Fee Amount: a;o Amount Paid t�11 Payment Date 3 3 611 f Payment Type Invoice# Check# 3 S Received By: �(C, EHD 48-02-025 SR FORM(Golden Rod) REVISED 1 111 712 00 3