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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST CONTRACTOR / SERVICE REQUESTOR REQUESTOR CHECK If BILLING ADDRESS El Type of Business or Property FACILITY ID # SERVICE REQUEST # %g# ( ) q^ ( otqg zip E7-5�zOQ STATE C-4 CITY t0 C_&�t 1'3�0c) S O `f Z9 MAY o 1 2007 OWNER I OPERATOR , T'A,*J-4 't/C��[l��ij1 -PHf �% CHECK If BILLING ADDRESSO TI �/�� 'l , " al/—O0(4V FACILITY NAME % SITE ADDRESS r r_ (,2,, ckY R •� J ENVIRONMENTAL Street Number Direction Street NameR� City ZiD Code Ncr� EMPLOYEE #: HOME or MAILING ADDRESS (If Different from Site Address) C4?3 –1 (J.J / EMPLOYEE #: Street Number Street Name Date Service Completed (if already completed): CITY ll STATE C14 zip P I E: -06 PHONE #1 EXT•APN # LAND USE APPLICATION # ( )qq3-7630 Payment Type ✓ Invoice # Check # l PHONE #2 EXT. BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR CHECK If BILLING ADDRESS El BUSINESS NAME PA- n k„ 4DOis r_ _ Od • PHONE#) � �/ _ Q EXT. HOME Or MAILING ADDRESSi -, Q ( V W V v� (!O I %g# ( ) q^ ( otqg zip E7-5�zOQ STATE C-4 CITY t0 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: — n / © 7 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: COMMENTS: R ECE I VEE MAY o 1 2007 SAN JOAQUIN COUNTY ENVIRONMENTAL ACCEPTED BY: 1 l t'LK Ncr� EMPLOYEE #: DATE: S r C ASSIGNED TO: , Ou A- I A -A OI EMPLOYEE #: G� (S� DATE: 5- —1-0 -7 Date Service Completed (if already completed): SERVICE CODE: '7-S11 P I E: -06 Fee Amount: V . ( Amount Paid C�i� — Payment Date S r `D Payment Type ✓ Invoice # Check # l Received By: EHD 48-02-025 SR FORM (Golden Rod) REVISED 11/17/2003