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SAN .JVAQU.1N I:UUN'I-Y L'NVIRONMIL;N'1'AL HEAL'I-H JJIEPAKI'Ml;'N'1' SERVICE REQUEST Type of Business or Property FACILITY IC# SERVICE REQUEST# �2 D C) ( z 16,6 OWNER/OPERATOR Jt;9 `'ff P �L A!]'DACtC CHECK If BILLING ADDRESS to FACILITY NAME PPe >Detc.K Pt2OflrF—" --] q SITE ADDRESS .y5op 4 E.• I V L,t_fK E� AVE . e!54--NL-01\J53 ao Street Number Dir tion Street Namo Ity zip code HOME Or MAILING ADDRESS (If Different from Site Address) Z99 00 &rTE9— R:D Street Number Strofit Name CITY � C�1-a�3 STATE CA zip gS32-0 PHONE#1 ExT. APN# LAND USE APPLICATION# (Z-01 ) 93*- 2-Woc' N/A PHONE#2 ExT. BOS DISTRICT LOCATioN CODE ( } C CONTRACTOR/ SERVICE REQUESTOR REOUESTOR Q� �ptC c z7 CtfEcKIf BILLING ADDRESS❑ BUSINESS 14AME L1,1C O^Y— PHONE# Err. I.2�1 DOME or MAILING ADDRESS ONS Sr. FAx# (710 CITv L.oD l STATE C. ZIP q 5-7-4-0 BILLING ACKNOWLEDGEMENT: 1, 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 FEDERAL Iaws. APPLICANT'S SIGNATURE: DATE: .PROPERTY/BUSINESS OWNER❑ OPERATOR MANAGER ❑ OTHER AUTHORIzED AGENT 0 CONS aL..i A^rr If APPLICRNT is not the P/LLING PARTY.proof Of authorization t0 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 environmentaUsite 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: ILEv LF—L-0 SO94 4 5t*3vR4z--AC-r CoN'rA M(AJPr-n ON 2CPr32.-i COMMENTS: qF RECE, NT (.i-I,fJI Erv�l� MAR z 8 2011 HEALVIOMIENTA� ACCEPTED BY: f�.�t v��{ EMPLOYEE#: (D-3z-f DATE: ASSIGNED TO: EMPLOYE€#: L�Q c{ - DATE: 3 � Date Service Completed (if already completed): SERVICECODE: 3 fS P I E: z6P03 Fee Amount: ��(�p� Amount Paid X44. 00 Payment Date ?>(2-91 11 Payment Type Invoice# Check# Received By: EHD 48-02-025 SR FORM(Golden Rod) REVISED 91/17/2003