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r�C�I��`��D SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT V 1 9 2007 SERVICE REQUEST ENVIRONMENT HEALTH of Business or Property FACILITY ID # NESS NAME A ` I l� C� I �.0 2 / , r - SEI &AMO CES MInnF,rLCIPrt-FUELI�Cc. E 03,E 5ef4vy�&Ll IER / OPERATOR S 4 ell, 1. A O ILCO PK(P A t4 C K CHECK If BILLING ADDRES r I tO TY NAME ♦ vt� ( x- k q7- -t- ACCEPTED BY: ADDRESS DATE: NT L(% A,T-E(Z L O O CZ -a S T- Q C lL T-0 t-( 9s' L O S 1010 () Street Number I Direction I Street Name city Zip Code or MAILING ADDRESS (If Different from Site Address) Amount Paid C� }� Pay m t Date Z_0 0 i t�W t,�-�i2 C' 14 S r Street Number Payment Type L/ Street Name - / O 2— �/ A v 13 v 2 P4 STATE C A ZIP 9 S-61 41 �T, APN # z— 3-�So�-o LAND USE` APPLICATION # 0) O3s-C)yo( #ZT ) BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR UESTOR I�jn I C A rz'� 1 / % A CHECK if BILLING ADDRESS® NESS NAME A ` I l� C� I �.0 2 / , r - COMMENTS: PHONE # Exr. r6 :�-Z - I( S- L E or MAILING ADDRESS O T� O v ! p L� l� FAX # ( 9t 6 ) -S LA ! C S -C' S %-'L2 A"O-li- p STATE C A, ZIP 91-5-6 q LING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, owledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project tivity will be billed to me or my business as identified on this form. certify that I have prepared this application atipi that the work to be performed will be done in accordance with all SAN JOAQUIN !vTY Ordinance Codes, Standards, ST and DERAL law . 2— LICANT'S SIGNATURE:/NDATE: t I 1 I b d PROPERTY / BUSINESS OWNER ❑ OPERATOR/ MANAGER U OTHER AUTHORIZED AGENT ba C tl t 2 A41" n__ 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: A-ni 2 V t VW COMMENTS: CE(VE� NOV 1 9 2007 SAN JOAQUIN COUN NVIRONMENTqL HE ACCEPTED BY: EMPLOYEE #: DATE: NT ASSIGNED TO: /_�!%� EMPLOYEE M DATE: Date Service Completed (if already completed): SERVICE CODE: P I E:2 0 Fee Amount: Amount Paid C� }� Pay m t Date Payment Type L/ invoice # Check # �j 3 a Received By: EHD 48-02-025 SR FORM (Golden Rod) REVISED 11/17/2003