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P w SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID # CHECK If BILLING ADDRESS SERVICE REQUEST # — /1(-L' EMPLOYEE #: PHONE # EXT' 2-9 S S/ — 004 OWNER / OPERATOR Y C � � A N T Vt DATE: CHECK If BILLING ADDRESS FACILITY NAME SERVICE CODE: v L (S''IITE ADDRESS G. / > R /,/ �8 ��ci L 11A Street Number Dlrectlon /a Street Nam ZipCode HOME or MAILING ADDRESS (If from Site Address) /Different t� CJTR `'t 7/ 1 L A 7 / / I CA4reet Number �J /T Street Name CITY STATE ZIP G [i PHONE tti EXT. APN # q l LAND USE APP LI ATION # L- � 6",53 �Lo P-/�c�O PHONE #2 EXT. BOS DISTRICT J ILoCAT�IONCO)z pI CONTRACTOR / SERVICE REOUESTOR REQUESTOR /")�/ /' A v,'- -" PZU M /3 f,/Y ' CHECK If BILLING ADDRESS BUSINESS NAME — /1(-L' EMPLOYEE #: PHONE # EXT' 2-9 S S/ — DATE: 2 1 J / ` — 5,!?/ Y HOME or MAILING ADDRESS 1 /Yt/,' ✓17 C G' c ,� L ✓ DATE: FAX # (2-S) S `% S CITY/ 2 4 SERVICE CODE: v L STATE 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�nda TATE and FED laws. APPLICANT'S SIGNATURE:: j DATE: 12 PROPERTY / BUSINESS OWNER ❑ OPERATOR I MANAGER ❑ OTHER AUTHORIZED AGENT LA:r) If APPLICANT Is not the BILLING PARTY, 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 t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It IS available and at the Same time It IS provided tQ me or my representative. / N TYPE OF SERVICE REQUESTED: ( / "01 , i 1 /S 4-1 rv/ - C I v`Q If i t r In io d / , COMMENTS: 0- / �J S _ _ f —/�- V f tC J Nt/iR0 J' 4TyO MF . ACCEPTED BY: EMPLOYEE #: �%� DATE: 2 1 J / ` ASSIGNED TO: EMPLOYEE #: DATE: Date Service Completed (if already completed): SERVICE CODE: v L PIE: 442 �2 Fee Amount: 1 5Z Amount Paid :` Payment Date Payment Type Invoice # Check # - Received By:, - EHD 48-02-025 07/17/08 SR FORM (Golden Rod) Fp 78 ry