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SAN JOAQUIN COUNTY Lt'NVIRONMEN-,t L KEPARTMENT SERVICFt QUEST Type of Business or Property FACILITY ID # PHONEJk It O 2'[ -7 -S SF ---'7T-7 SERVICE REQUEST FAX # ( ) CITY Z Z S STATE 2 ZIP f r��,_� S#, OWNER / OPERATOR E] L^�� l l I /�t� CHECK If BILLING ADDRESS FACILITY NAME _ EMPLOYEE #: SITE ADDRESS ASSIGNEn TO' r- // nATr I } Date Service Completed (N already completed): { Sheet Number D4rectlen PIE:Ito ` Street Name city Zip Crude HOME or MAILING ADDRESS (If Different from Site Address) 2.ZU Invoice # Check #s �� OV Co Street Number Street Name CITY 7--,) 1 ACV'( O u Q Z- STATE ZIP C-4 PHONE #1 EXT. l PN # LAND USE APPLICATION # PHONE #2 EXT. ( ) BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR CHECK if BILLING ADDRESS , , `+ BUSINESS NAME r S� „ I t PHONEJk It O 2'[ -7 -S SF ---'7T-7 HOME or MAILING ADDRESS a e Ptd t o3_�0� FAX # ( ) CITY Z Z S STATE 2 ZIP f BILLING ACKNOWLEDGEMENT: 1, the undersigned property or business owner, operator or authorized qgent of same, acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associatedr or activity will be billed to me or my business as identified on this form. r Cj� I also certify that I have prepared this application and that the work to be performed will be done in accordance Wi �1lSANVIYAD COUNTY Ordinance Codes, Standards, STATE and FEDERAL laws. iyY L 9 201 APPLICANT'S SIGNATURE: DATE: S �t 8 PROPERTY / BUSINESS OWNER ❑ OPERATOR / MANAGER b OTHER AUTHORIZED AGEN•1' M If APPLICANT is not the BILLING PARTY, proof of authorization to sign is require Title T 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 JOAQUIIJ COUNTY ENVIRONN ENTAL HEALTH DEPARTM -N-r as soon as it is available and at the same time it is provided to me or my representative. TYPE OF SERVICE REQUESTED: 0.p- �7 �` �'— �� - -, - ECEIV D COMMENTS: MAY 29201 r��,_� ENVIRONMENTAL DEPARTME.:%• ACCEPTED BY: _ EMPLOYEE #: DATE: 12-9 11 C t, lVJ ASSIGNEn TO' r- EMPLOYEE ' nATr I } Date Service Completed (N already completed): SERVICE CODE: PIE:Ito ` Fee Amount*ts' , oZ) Amount Paid 4�S&v Payment Date Payment Type e Invoice # Check #s �� Received By: EHD REVISEDSED 11 11/11 7/2003 SR FORM (Golden Rod) iV kLFI