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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property CHECK if BILLING ADDRESS FACILITY ID # SERVICE REQUEST # R F -A- I L F V E -t - HOME or MAILING ADDRESS rozr LS 't l FAX# (91(P)34 -3-1(3-L (4 2) 1 OWNER /OPERATOR (GL U (V_ S \ " tl' ► r SIA (Z IL "--, r C CHECK If BILLING ADDRESS FACILITY NAME %� V f / -� / � Z— 6J� lC SITE ADDRESS I/ �e- G A, _ C O I,/ -''l o b ( � L V Q ('4 -- ( Street Number Direction Strre_et Name t V city DATE: S/ O Zio Code HOME or MAILING ADDRESS(if Different from Site Address) DATE: ;S- ` a Date Service Completed (if already completed): — S 6 )- V ' , ( S&- 'Sl-- Street Number PIE:'D2 C, Street Name CITY Fr�-E ✓�^^ - , T— � ` Gi STATE C ZIP PHONE #1 ExT• (s(a ) s -o 0 o— APN # 2G_;{� LAND USE APPLICATION # PHONE #2 ExT• BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REOUESTOR REQUESTOR A� ,� ,�^' I C 14rY{� WA- C 1 4'q CHECK if BILLING ADDRESS BUSINESS NAME 1 / A L ^ri �� E� j�(r C PHONE # ExT• It 6 3 3- t (S- i._ --- HOME or MAILING ADDRESS rozr FAX# (91(P)34 -3-1(3-L CITY ^� STATE C 4 ZIP '?S-6 Q ( 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, TA an EDERAL laws. APPLICANT'S SIGNATURE: DATE: f .�f o C PROPERTY/ BUSINESS OWNER ❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT 1Z 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. U S 'T L) F- t'7— TYPE 'T TYPE OF SERVICE REQUESTED: P ( 2 IP- U L P --Ad A -Aa ) PAYMENT COMMENTS: MAY 12 2008 SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT ACCEPTED BY: t V EMPLOYEE Mf 13 Z/ DATE: S/ O ASSIGNED TO: /J C -(G ��S EMPLOYEE #: i(1 3 DATE: ;S- ` a Date Service Completed (if already completed): SERVICE CODE: l� PIE:'D2 C, Fee Amount: Amount Paid Gi Payment Date Payment Type o— Invoice # Check # 1 L Received By: EHD 48-02-025 SR FORM (Golden Rod) REVISED 11/17/2003