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JAN JOAQUILN I.UUNIY 1,NVIKUNMEN'I'AL nEAL'I'H 1JEYAKI'MEIY1 SERVICE REQUEST Type of Business or Property FACILITY ID# SERVICE REQUEST# OWNER/OPERATOR /� (Zp (SI:..G �JR-NS CHECK If BILLING ADDRESS 121 FACILITY NAME SpE uK�� (Zp Nc H SITEADDRESS 2LOS t LJ) I-(Z- R—C> L_0D \ 9S-2-4D Street Number I Direction Street Name City Zip HOME Or MAILING ADDRESS (If Different from Site Address) o. i3 DX 1` 1J I.0 Street Number Street Name CITY W0-01>5Z1bCrC: STATE CIS ZIP CiS2SS PHONE#t En. APN# LAND USE APPLICATION# (zoq) 4Q1 -(,9r1 o13 - oso - 19 PHONE#Y Eu. ENDS DISTRICTO� LOCATIO CODE ( ) ql9 CONTRACTOR! SERVICE REQUESTOR REQUESTOR R-k�1.g y (2^c c— 7 CHECK if BILLING ADDRESS❑ BUSINESS NAME L I V E O^Ie— PHONE# Ex*. Z�l 3('P9 • 03}� HOME or MAILING ADDRESS fill ft�. ST• FAX# O (Zo91 CITY STATE CA ZIP C1C) BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or audiorized 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 fort I also certify that I have prepared this application and that performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes,Standards,STA s APPLICANT'S SIGNATURE: DATE: PROPERTY/BUSINESS OWNER 70R/ GER ❑ Or.AUTft ..V AGENT 13 IfAPPLICANT is not the BILLING PARTY.proof of authorization to sign is required mete 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 t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it i3 available and at the Same time it is provided to me or my representative. TYPE OF SERVICE REQUESTED: (.VIEW %OR-FACE_- + SV5SUIZ•FACE Gd MAIM/rJdtT tO rV ft.l_, IPd�T COMMENTS: 1017--s'1i3 REC MENr W�aLT Ra,1k7JE4> E►VED '-; 4S-4e``0T-'r0 MAR 21 2013 ACCEPTED BY: Aim a-4^ EMPLOYEE#: DATE: ThIsk111113 ASSIGNED TO: /� - EMPLOYEE#: DATE: Date Service Completed (if already completed): SERVICE CODE: 315 PIE. Z6 03 Fee Amount: Amount Paid,4 goo.DZ) Payment Date Y2,111-3 Payment Type Invoice# Check# 2-2-2--71 Rece ed By: EHD 49-02-025 SR FORM(Golden Rod) REVISED 11/17/2003