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SAN JOAQUIl�(JUNTY ENVIRONMENTAL HEALTiJEPARTMENT SERVICE REQUEST Type of Business or Prop rt WG1- 1. c� S �v BUSINESS NAME W Gp�U/b /I _p L4 f ,( � (tel IeI FACILITY ID # 2 HOME or MAILING ADDRESS 3o 3 ZOlt SERVICE REQUEST # OWNER / OPERATOR , y fGl \ s' d� CITY C `C q A, CHECK If BILLING ADDRESS ❑ FACILITY NAME n , ,I a l.(�l C1 ,1....t �I e UUU ___ EMPLOYEE #: SITE ADDRESS .3 0 3 2 Street Number Direction �.-1 , . / P-0 � U U�1�` Street Name SERVICE CODE: tip O �Ci Zip Code HOME or MAILING ADDRESS (If Different from Site Address) Street Number Amount Paid �g S Street Name CITY Payment Type Invoice # STATE ZIP PHONE #1 EXT. (Lvq) u4(0 Received By: APN # LAND USE APPLICATION # PHONE #T EXT. ( ) BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR lA ry- PCA1 l �) CHECK if BILLING S BUSINESS NAME W Gp�U/b /I _p L4 f ,( � (tel IeI %ADDRESS PHONE# LA V VJ J l ExT. HOME or MAILING ADDRESS 3o 3 ZOlt I 1 FAX# CITY C `C q A, L- ) STATE ZIP 45k j 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:—(� ( out/,,— DATE: PROPERTY / BUSINESS OWNER ❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT ❑ 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: S / COMMENTS: C^ � r� S Gt.vl fi �� a %Ae ` A RECE E tl MAY 1 0 2007 TAILTM SAN JOAQ NIN COrmviROMEN ACCEPTED BY: / EMPLOYEE #: bWAt-TH DE A ASSIGNED TO: EMPLOYEE #: DATE: Date Service Completed (if already Completed): SERVICE CODE: P / E: ZW Fee Amount: K Amount Paid �g S Payme t Date S� a 0? Payment Type Invoice # Check # S % (o Received By: EHD 48-02-025 SR FORM (Golden Rod) REVISED 11/17/2003