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V 40 • 0 SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property (> O �•( RECEI VEQ FACILITY ID # SERVICE REQUEST # L rZE'TA,('FV 1%L # t6 Err. 313 —ccrL '5;' 400 OWNER / OPER//ATOR kR V L �C — �� 4A- CHECK If BILLING ADDRESS FACILITY NAME CITY ^ C 2 A, VA 5-11� SITE ADDRESS ZIP p S-6 R � SERVICE CODE: P / E:� vo•�7 Fee Amount: O 0 Street Number Direction Street Name city Zip Code HOME or MAILING ADDRESS (If Different from Site Address) Check # t T �(2 P Yt- L S K-- 'el Street Number Street Name CITY �(Z E AA B LL 4\ STATE C A ZIP PHONE #1 ExT.APN # LAND USE APPLICATION # (S -to) 6 s}- gS-o 0 PHONE #2 EXT. ( I BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR (C W "'t/ r , i � LT- r �(/ w`l (> O �•( RECEI VEQ CHECK If BILLING ADDRESS BUSINESS NAMEPHONE (,(iALTpnl, L��..c�L�2r�<, ,�r_ # t6 Err. 313 —ccrL HOME Or MAILING ADDRESS p , o / oz 5,- DATE: FAX # ( 16) 33 CITY ^ C 2 A, VA 5-11� STATE CA ZIP p S-6 R � 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 aV that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, Standards, STTE and ERAL la APPLICANT'S SIGNATURE: DATE: Z �40 �- PROPERTY / BUSINESS OWNER ❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT C ASD IL-- 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. PA Yi\ A c n I -r TYPE OF SERVICE REQUESTED: ( A_( V IFS (> O �•( RECEI VEQ COMMENTS: JUN 2 6 2007 SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT ACCEPTED BY: EMPLOYEE #: DATE: ASSIGNED TO: lil U iA t p A ( )> `f EMPLOYEE #: -2-6 DATE. Date Service Completed (if already Completed): SERVICE CODE: P / E:� vo•�7 Fee Amount: I Amount Paid g S, Paymen Date Payment Type Invoice # Check # Received By: EHD 48-02-025 SR FORM (Golden Rod) REVISED 11/17/2003