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SAN JOAQUW—OUNTY ENVIRONMENTAL HEALT0-PARTMENT SERVICE REQUEST Type of Business or Property 6,a 66 l-5 n1 itrvj FACILITY ID # BUSINESS NAME S�-atltee, SERVICE REQUEST # OWNER I OPERATOR 5L d tl O, ,r(_ �rU(� :' i` CHECK if BILLING ADDRESS FACILITY NAME .11 (� G$7�✓ant Li r� Sh Gll FAX # o SITE ADDRESS 2.3-fC-7, Stet Number re t _ I, Direction t•�, Street Name Tr2c, Ci 15374o Zip Code HOME or MAILING ADDRESS (if Different from Site Address) Street Number Amount Paid Street Name CITY STATE ZIP PHONE #1 EXT. 1 1 APN # LAND USE APPLICATION # PHONE #2 ExT• BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR' I2r:1 � 0 BILLING CHECK If BILLING ADDRESS BUSINESS NAME S�-atltee, JUN 1 9 2008 JUN 19 2008 ENUIRONMEN -1 HEALTH SAN JOAQUIN COUNTY PER IT/SERVIGFS ENVIRONMENTAL HEALTH DEPARTMENT ExT. PHONE 9D7 "7&D -1&(b0 to-17- HOMkOLMAILING ADDRESS' 1*57 t • 11 G,2 4� 11 b'/J. DATE: FAX # o CITY f et2lUMa STATE G¢ ZIP 94q54- 4g54 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 draws. APPLICANT'S SIGNATURE: pn 6,--k2 H 4 A6L-- 1 L,� t'21 2yV'-4 DATE: 61614* PROPERTY / BUSINESS OWNER ❑ %ERATOR / MANAGER 13OTHER AUTHORIZED AGENT Men} iw AWe, h-aifit. -.T ifAPPLICANT is not the BILLING PARTY, proof of authorization to sign is required rate 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 itis rovided to me or m representative. P Y p i "1 � 11 TYPE OF SERVICE REQUESTED: PAYMENT COMMENTS: JUN 1 9 2008 JUN 19 2008 ENUIRONMEN -1 HEALTH SAN JOAQUIN COUNTY PER IT/SERVIGFS ENVIRONMENTAL HEALTH DEPARTMENT ACCEPTED BY: EMPLOYEE #: DATE: ASSIGNED TO: EMPLOYEE #: IC� Z DATE: Date Service Completed (if already completed): SERVICE CODE: g P I E: Fee Amount: 2 Amount Paid Payment Date Payment Type Invoice # Check # D�� ecei ed By: EHD 48-02-025 SR FORM (Golden Rod) REVISED 11/17/2003