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. 1b From: 08/009 15:37 08/28/2009 13:11 209454 1 8 ENVIRONMENTAL IHEALT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMEN'r SERVICE REQUEST #866 P.002/002 PAGE 02/02 Type of Business or Property � F !% FACILITY ID # YMENT SERVICE REQUEST # S Lf 9 R SEP -1 2009 SANN�RONMEPITAI- NEA1-N DEPAR�EPIT Acmpm BY: P Lf v E ( OWNER 1 OPERATOR n Z/ DATE; I D ASSIGNED TD:(a at P .e e CT— CHECK if B,ltl,(NG ADDRESS FACItry NAME L DATE: Date Service Completed (if already completed): SITE ADDRESS i 1 a MIBJ ri- 1Z Fa® Amount: t� Amount Paid et Num Payment Date �e Payment Type ✓ Invoice # 2i Code HOME Or MAILING ADDRESS (if Different from Site Address) SIci S Received By: _ sfg"t Nuftet 91reel Name CITY STATE Z!P PRONE #1 EXT. APH # dSS- 2-L((9-18 LANA USE ARpuCATION # c , PHONE#Z Err, SOS DISTRICT LOCAN ODE REQUESTOR BUSINESS NAME HOME or MAILING ADDRESS CRY i A J n `1-, CONTRACTOR / SERVICE REQUESTOR CHECK if FAX (Q) STATE r A _ zip BILLING ACISNQWI.IvJ)GEMENT: 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 Ordirrance Codes, Standards, STATE and FEDERAL laws. 0j 2 f1 APPLICANT'S SIGNATURE: l,, DATE: 0` J t V PROPERTY / HtlsiNf Ss O%vtiER ❑ OPFRATOR / MA YAGF.R ❑ OTHER AUTHORIZED AGENT ❑ IfAPPII ANrLT not the BILLING PARTY, proof of authorization to sign isrequired Tele AUa MIZAnQN TO RELEASE INFORMATION: When applicable, I, the owner DT operator of the property locatedat 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 fIEAI,TH D'FPARTMFNT as soon as it is available and at the same time it is provided to me or try representative, TYPE Of SERME REQUESTED: UST— � F !% YMENT COItMEM: R SEP -1 2009 SANN�RONMEPITAI- NEA1-N DEPAR�EPIT Acmpm BY: P Lf v E ( EMPLOYEE #. Z/ DATE; I D ASSIGNED TD:(a at P .e e CT— EMPLOYEE #:Z L DATE: Date Service Completed (if already completed): SERVICE COVE: Fa® Amount: 3 S (� G Amount Paid Lfj S _ Payment Date cl Payment Type ✓ Invoice # Check # SIci S Received By: _ RHD 46-02-D25 SR FORM (Golden Rod) REVISED 14/1712003 M.