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I 'W SAN JOAQU&OUNTY ENVIRONMENTAL HEALTALPARTMENT SERVICE REQUEST Type of Business or Property 4:rLFACILITY ID # TS SERVICE REQUEST # 'Oosp vT- 4L 0 r --m Pa 6vA Royb -5 y OWNER / OPERATOR 1( L.00 I M5—MORiA-L qMP I rA-L CHECK if BILLINGADDRESS� FACILITY NAME I Mr'-w)g IkL- IAsp vrl'L SITE ADDRESS 1-7 5U 1 FSO T-0 N I RN1O Q T F� F . EALf H DEPARTMENT LO IJ I C154-0 Street Number 01, tion ASSIGNED TO: Street Name EMPLOYEE M city Zip Code HOME or MAILING ADDRESS (If Different from Site Address) SERVICE CODE: OP I E...? Fee Amount: `' Amount Paid Street Number Payment Date © O Street Name CITY STATE ZIP PHONE #1 EXT. uo)334-34-11 APN # G3i -0-7o- 44 - LAND USE APPLICATION # PHONE #Z EXT. ) 339 - 74g+ BOS DISTRICT --IF OCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR w�� 1 1H LE1 .1 \ ' \. ��`iiVVV 1 1 L,SC I4 CHECK If BILLING ADDRESS Er BUSINESS NAME k,siALEY kA - Wil -so" PHONE # EXT• 53 56-7 -�,a2 g HOME or MAILING ADDRESS © r --m Pa 6vA Royb FAx ( ) Q 5! 0 2 STATE ZIP CITY tL- 1 R PtQC C& 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, Standards, STATE and FEDERAL laws. APPLICANT'S SIGNATURE: DATE: DATEStv : y PROPERTY / BUSINESS OWNER ❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT E/ O i1 iii R(� 1—C�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 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: PAYMENT COMMENTS: MAY 2 2008 JOAQUIN COUNTY SAN ENVIRONMENTAL EALf H DEPARTMENT ACCEPTED BY: EMPLOYEE M DATE: ,y ASSIGNED TO: EMPLOYEE M ��i Z DATE: Date Service Completed (if already completed): SERVICE CODE: OP I E...? Fee Amount: `' Amount Paid $ g- Payment Date © O Payment Type Invoice # Check # R ceiv d By: EHD 48-02-025 SR FORM (Golden Rod) REVISED 11/17/2003