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SAN JOAQUIPPOUNTY ENVIRONMENTAL HEALTH PEPARTMENT SERVICE REQUEST �1� Type off Business or Property FACILITY ID # BUSINESS NAMEf� kswi-r.y `SERVICE REQUEST # -tOSPIi'�� HOME or MAILING ADDRESS`` , 1 - Q N (� E RArn1C,L1 QgP, \ -5# OWNER / OPERATOR )-0D I r A S t,&0 ,1 PrL ' i a 1P 1 .�-- A- _ ENVIRONMENTAL. EALTH DEPARTMENT CHECK if BILLING ADDRESS � FACILITY NAME 1 MEMkop -i_ 16sv) I.T -- ASSIGNED TO: EMPLOYEE #: DATE: SITEADDRESS I r So L) I P',9,NA0 Q E P I E. -;% O"-7 1 LD1 L 645Q4-0Street Number Direction Payment Type Street Name Check # CI i Code HOME or MAILING ADDRESS (If Different from Site Address) Street Number Street Name CITY STATE ZIP PHONE #1 EXT• 00)334-34-11 APN # csi •o -7Q- - - LAND USE APPLICATION # PHONE #2 EXT 741 � BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR k:St` F•1 L_ILy �V I, �-_ 50 N CHECK If BILLING ADDRESS BUSINESS NAMEf� kswi-r.y i VA - \t'U iLSOM( PHONE# EXT. 53 561 '" (6-:2DO HOME or MAILING ADDRESS`` , 1 - Q N (� E RArn1C,L1 QgP, FAX # ( ) CITY 1RP,oo n I / 3 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, Standards, STATE and FEDERALflaws. APPLICANT'S SIGNATURE: �G'�>---=--' DATE: �2- 7l PROPERTY / BUSINESS OWNER ❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT L`7 d -% T-RTCP, IfAPPLICANT 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 SAN jOAQUIN COUNTY ENVIRONMENTAL. EALTH DEPARTMENT ACCEPTED BY: EMPLOYEE #: DATE: ASSIGNED TO: EMPLOYEE #: DATE: Date Service Completed (if already completed): SERVICE CODE: D 2d P I E. -;% O"-7 Fee Amount: "' Amount Paid 7", Payment Date � g Payment Type Invoice # l Jl S Check # R ceiv d By: EHD 48-02-025 At, CD SR FORM (Golden Rod) REVISED 11/17/2003