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aAIV J VAq V i1V L V V 1V 1 Y P.1V V 11CV1V1V1L'1V 1 AL 1111.AL 1 li iJEYAtC 11V11S1V 1 SERVICE REQUEST ' Type of BBBAiness of Property FACILITY ID# SERVICE R�S# OWNER I OPERATOR CHECK If BILLING ADDRESS re>S FACILITY NAME ti` /I�rtr7l ! / QnGLjcl`�a� S SITE ADDRESS 34 RJ _S-, �eZ G ��e t 64 �l e/�J7 ca Street Number Direction Street Name city Zip Code HOME Or MAILING ADDRESS (If Different from Site Address) D 'i- Sk Glr&J d to C i' Street Number Street Name CITY sa STATE ZIP a �0 5� e 9-e PHONE#1 EXT. APN# LAND USE APPLICATION# ( ) 93 3 40 - 0 ,9 .W-X000050 PHONE#2 Ext. BOS DISTRICTT, LOC ON CODE ( ) /V CONTRACTOR/ SERVICE REQUESTOR REOUESTOR i-,/a r.�G st Ir_ - vv k TCHECK If BILLING ADDRESS BUSINESS NAME G PHONE# Ear. C, w(-L I�/V G� a 0? Lt-7t—�jef"23 HOME or MAILING ADDRESSC- f FAX# S 3 SJR �rD I O-V:a I 6CVY C 1/t k A • ( ) CITY STATEG� ZIP r—k+& _ 45•oZ16- BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or project specific ENvntoNmENTAL 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 FEDERAL 1 --- APPLICANT'S SIGNATURE: DAT�EL7 PROPERTY/BUsINESs OWNER❑ OPERATOR/IVIA GER ❑ OTHER AUTHORIZED AGENT G1VIL r'NGr'/� — If APPLICANT is not the BILLING PARTY proof of authorization to sign is required Title AUTHORIZATION TO RELEASE INFORMATION: When applicable,1, 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: AQej//.e SU Fi4GC c.S�}1' SUl?�gGE CaA1,r A/J4Pa✓ fi3lef� COMMENTS: PAYMENT RECEIVED MAY 10 2010 SA TM ENVI RCN_MENTAL WNT ACC TED BY: EMPLOYEE#: j�� DATE: ASSI 0. �h��P � ty� EMPLOYEE#: S�fj� DATE: Date Service Completed (if already Dom ed): SERVICE CODE: 3/✓! PIE: a� Fee Amount: Amount Paid (� Payment Date Payment Type Invoice# Check# Z07 1 Receive By: EHD 48-02-025 -- .SR FORM(Golden Rod) REVISED 11/17/2003