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000493 SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or property • i+cu CHECK if BILLING ADDRESS O BUSINESS NAME Wes •-�eir-n Pf�cm_.p i l n 6 FACILI Y IO # J j.• 3 P ONE# EXT. 510.21 �� SERVICE REQUEST # S i<'- o o S Z. `1 Z` OWNER / OPERATOR FAx [� �7 , "'7 1+ CA p .G-. i /� (� CITY ,San p�C C� CHECK If BILLING ADDRESS D FACILITY NAME Loot-1STC VI�W1 l HEALTH DEPARTMEN SITE ADDRESS �•—'�� Street Number Dlr ctlonTSireel Feu rmon- /41* N DATE: � I Cit 04 Zia Code HOME or MAILING ADDRESS (If Different from Site Address) Street Number DATE: + -2- Street Namo CITY PIE: C STATE ZIP PNON 1 EXT. APN # 07 / sD LAND USE APPLICATION # PHONE#2 EXT. Check # BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR j�r , � „r� p, REQUESTOR Dano, i1L f�-/W/Lf 1�/ CHECK if BILLING ADDRESS O BUSINESS NAME Wes •-�eir-n Pf�cm_.p i l n 6 COMMENTS: ballon P ONE# EXT. 510.21 �� HOME or MAILING ADDRESS t' T r FAx [� �7 , "'7 1+ CA p .G-. i /� (� CITY ,San p�C C� STATE � ZIP � x.14 � 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 we 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 an - 'DERAL laws. r�f3I 7 APPLICANT'S SIGNATURE:% - -I DATE: ,�J PROPERTY / BUSINESS OWNER OPERATOR I ANACER Li OTHER AuTHORIZFD AGENT i le If APPLICANT is not the BILLING PARTY proofof antherilation to sign is required TLr AUTHORWATION 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 environtnental/site assessment information to the SAN JOAQUIN COUNTY ENVIRONMGNTAI. IiEALTH DEPARTMENT as soon as it is available and at the same time it is -nmvided to me or my renresentative. i AY M E I TYPE OF SERVICE REQUESTED: I' I.11 S j Y�t✓L 0 COMMENTS: ballon unde�c��tc.rl�l 5��a�� t-anK• DEC 1 3 2007 SAN JOAQUIN COUN ENVIRONMENTAL HEALTH DEPARTMEN ACCEPTED BY: 0C f L' i rL > EMPLOYEE #: C Z DATE: ASSIGNED TO: Ham_ EMPLOYEE #: (E' Z— DATE: + -2- Date. Service Completed 4if already completed): SERVICE CODE: Date PIE: C Fee Amount: I Amount Paid Payment Date 07 / sD Payment Type Invoice # Check # Received By: EHD 48-02-025 SR FORM (Golden Rod) REVISED 11/1712003